REPORT …

                                          REPORT

                                              OF

                               TERMINATION OR ASSUMPTION

                                              OF

                                  PUBLIC EMPLOYMENT




I __________________________________, a member of the Senate/General Assembly (circle
                  PRINT NAME

one) am filing this report in accordance with the requirements of section 2:14 of the Code of

Ethics. Please be advised that I have/my spouse has (circle one) terminated/assumed (circle

one) the following public employment as of ______________________ (date):




       ___________________________________________________________________
       public employment (note position title and public entity in which position is held.




_________________________                   _____________________________________
           DATE                                         ORIGINAL SIGNATURE




This completed report is required to be filed within 30 days of any termination or assumption
of public employment by you or your spouse. The completed report containing an original
signature should be returned to: Joint Legislative Committee on Ethical Standards, 2nd Floor,
State House Annex, Room 210, PO Box 068, Trenton, New Jersey 08625-0068.