TOWN OF BROOKHAVEN BOARD OF ETHICS
TRANSACTIONAL DISCLOSURE FORM
APPLICANT NAME:
LAST NAME, FIRST NAME
APPLICANT ADDRESS:
STREET, APT.
CITY STATE ZIP CODE
NATURE 0F APPLICATION: (CHECK ALL THAT APPLY)
TAX GRIEVANCE APPROVAL OF PLAT
VARIANCE EXEMPTION FROM PLAT OR OFFICIAL MAP
AMENDMENT LICENSE OR PERMIT
CHANGE OF ZONE OTHER:
DOES ANY OFFICER OF THE STATE OF NEW YORK, OFFICER OR EMPL0YEE OF THE TOWN OF BROOKHAVEN,
OFFICER OR EMPL0YEE OF SUFFOLK COUNTY, OFFICER OF A POLITICAL PARTY IN SUFFOLK COUNTY OR HIS
OR HER SPOUSE, BROTHER, SISTER, PARENT, CHILD, GRANDCHILD, OR THE SPOUSE OF ANY OF THEM HAVE
AN INTEREST IN THIS APPLICATION BY VIRTUE OF BEING THE ACTUAL APPLICANT, OR, BY VIRTUE OF
HAVING AN INTEREST IN THE CORPORATION, PARTNERSHIP, OR ASSOCIATION MAKING SUCH APPLICATION?
YES NO
IF YOU ANSWERED "YES", COMPLETE THE REST OF THE FORM AND DATE AND SIGN WHERE INDICATED.
IF YOU ANSWERED "NO”, SIMPLY SIGN AND DATE THE FORM WHERE INDICATED.
INTERESTED PARTY AND NATURE OF INTEREST
NAME:
ADDRESS:
TITLE: DEPARTMENT:
RELATIONSHIP TO PUBLIC OFFICER/EMPL0YEE AND HIS OR HER TITLE IF 0THER THAN
SELF
:
INTERESTED PARTY:
YES NO
A.) IS THE OWNER OF GREATER THAN FIVE PERCENT (5%) OF THE CORPORATE
STOCK OF THE APPLICANT WHEN THE APPLICANT IS A CORPORATION WHOSE
STOCK IS LISTED ON THE NEW YORK OR AMERICAN STOCK EXCHANGES;
B.) THE ACTUAL APPLICANT;
C.) AN OFFICER, DIRECTOR, PARTNER, OR EMPL0YEE OF THE APPLICANT; OR
D.) LEGALLY OR BENEFICIALLY OWNS OR CONTROLS ANY STOCK OF A NON-
PUBLICLY TRADED CORPORATE APPLICANT OR IS A MEMBER OF A
PARTNERSHIP OR ASSOCIATION OF THE APPLICANT.
DATE
SIGNATURE OF APPLICANT
click to sign
signature
click to edit
![]()
