New Covered Person or Ethics Liaison Form

General Information

First and Last Name of Person Submitting Form

Position

Agency/Board Information Being Updated

Email of Person Submitting Form

First and Last Name of New Board Member or Agency Employee

Email Address of New Board Member or Agency Employee

Telephone Number of New Board Member or Agency Employee

If a Board Appointee, What Governmental or Private Entity Appointed New Member?

First and Last Name of Person Formerly in Position or Who New Board Member is Replacing

If Employee, Enter Position Number

Identify Employee Position Title Or, if Board Member, Statutory Board Position Filled

If Change in Covered Employee, Effective Date of Change

If New Board Member, Beginning Date of Term

If New Board Member, Ending Date of Term

First and Last Name of New Ethics Liaison

Email of New Ethics Liaison

Telephone Number of New Liaison

Name of Board or Agency Ethics Liaison Will Assist

Effective Date of Ethics Liaison Change