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(TYPE ALL INFORMATION -- SIGN IN BLACK INK) (State University of New York at Farmingdale)

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(TYPE ALL INFORMATION -- SIGN IN BLACK INK)
Name of Appointee:
(Last Name)
(First Name)
(Middle Initial)
I do hereby pledge and declare that I will support the constitution of the United States, and the constitution of the
State of New York, and that I will faithfully discharge the duties of the position of
Title of Position:
Agency Name:
Agency Code:
according to the best of my ability.
X
(Signature of Appointee) (Date)
**************************************************************************
PUBLIC OFFICERS LAW §78 CERTIFICATE
I, the Appointee named above, hereby acknowledge receipt of a copy of sections 73, 73-a, 74, 75, 76, 77 and 78 of
the Public Officers Law, together with such other material related thereto as may have been prepared by the
Secretary of State, and I acknowledge that I have read the same and that I undertake to conform to the
provisions, purposes and intent thereof and to the norms of conduct for members, officers and employees of the
legislature and state agencies.
X
(Signature of Appointee) (Date)
(Appointee must sign both the State Employee Statement in Lieu of Oath and the Public Officer's Law §78 Certificate)
Go to www.dos.ny.gov for filing instructions.
DOS-1690-f (Rev. 03/16) Page 1 of 1
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(TYPE ALL INFORMATION -- SIGN IN BLACK INK) (State University of New York at Farmingdale)

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Completed 24 July 2020

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