Fillable Ramapo College of New Jersey Annual College and (Ramapo College)

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Ramapo College of New Jersey Annual College and (Ramapo College)

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Revised SEC 12/2010 JF
Ramapo College of New Jersey
Annual College and University Disclosure Form
Statement Date: _______________________________ Academic Year: July 1, 20_____ – June 30, 20 _____
First Name: Last Name: _______________________________________
Institution: ______________________________ School: HGS ASB CA SSHS TAS
Title: _____________________________________________________________________________________________
Daytime Telephone: ____________________________ Email: ____________________________________________
Instructions: This form MUST be submitted pursuant to N.J.A.C. 19:61-6.10(a), which requires a State official serving in a scholarly
capacity to annually disclose to his/her Department Head any travel, subsistence or entertainment expenses, honoraria, academic
prizes or other things of value related to activities performed in a scholarly capacity received in the prior academic year. (July 1
st
through June 30
th
). Any benefit received related to your State position, and any outside activity performed, while not acting in a
scholarly capacity, must still be reported pursuant to your institution’s procedures, and on the forms required by the State Ethics
Commission. Enter “N/A” in any category in which you did not receive benefits while acting in a scholarly capacity during the
covered academic year.
Benefits Received
A. List below any benefit you received, from any source outside Ramapo, including but not limited to, travel
subsistence or entertainment expenses.
Type of Benefit Benefit Amount Source
Example: Travel $500 National Book Club
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
Attach additional page(s) if necessary
B. List below any benefit you received, from any source outside Ramapo, including but not limited to, honoraria,
academic prizes, or other things of value.
Type of Benefit Benefit Amount Source
Example: Honoraria $500 National Book Club
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
________________________________ _______________________ ________________________________
Attach additional page(s) if necessary
* Indicate whether the source of the benefit is an interested party to your institution. Interested Party means: 1) any person or entity
your institution regulated, licenses or supervises; 2) any grantee or grantor to your institution and any employee, representative or
agent thereof; 3) any supplier/vendor to your institution; 4) any advocacy group that advocates or represents the positions of its
members to your institution; 5) any organization a majority of whose members fall under 1-4 above.
Attach additional page(s) if necessary
Revised SEC 12/2010 JF
C. Assigned Educations Texts or Materials
Do you assign educational materials authored by you as a course requirement? Yes No
If yes, do you receive royalties from those educations materials? Yes No
If yes, did you donate those royalties? Yes No
If yes, where were the royalties donated?
________________________________________________________
To the best of my knowledge and belief the information on this form is true and accurate
Faculty Signature: ______________________________________ Date: ________________________
Dean Signature: ________________________________________ Date: ________________________
ELO Signature: ________________________________________ Date: ________________________
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Ramapo College of New Jersey Annual College and (Ramapo College)

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Completed 25 August 2020

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