New Covered Person or Ethics Liaison Form

Submitted by ccurry5 on Tue, 01/31/2023 - 14:48

General Information

First Name of Person Submitting Form

Last Name of Person Submitting Form

Position

Agency/Board Information Being Updated

Email of Person Submitting Form

First Name of New Board Member or Agency Employee

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 Who Appointed New Member?

First Name of Person Being Replaced

Last Name of Person Being Replaced

If Applicable, Enter Position Number

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

Effective Date of Change

If Applicable, Date that Board Member’s Term Will End

Additional Information

First Name of New Liaison

Last Name of New Liaison

Email of New Ethics Liaison

Telephone Number of New Liaison

Name of Board or Agency Ethics Liaison Will Assist

Effective Date