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COMMONWEALTH OF MASSACHUSETTS  

HUMAN RESOURCES DIVISION

CONTRACT EMPLOYEE DISCLOSURE FORM

 

 

IMPORTANT

  1. Type or print clearly in black or blue ink.
  2. Answer every question fully and accurately.
  1. Read certification and release carefully before signing.
  2. Return completed application.

 

 

PERSONAL INFORMATION

Name   (First)                  (Middle)            (Last)            Mr.   Mrs.    Ms.   Miss

 

 

Home Telephone Number

Mailing Address   (Street)             (City)             (State)             Zip(Postal) Code 

 

 

Home Address   (if different from mailing address)       

                              (Street)             (City)             (State)             Zip(Postal) Code 

 

 

Business or Message Phone:

 

E-Mail Address:

 

CONTRACT EMPLOYMENT

POSITION APPLIED FOR:

 

 

Agency: 

 

IMMEDIATE FAMILY WORKING IN MASSACHUSETTS STATE GOVERNMENT

 

Per Executive Order 444, please disclose any immediate family members, including those related to your immediate family by marriage, who are employed by the Commonwealth of Massachusetts .  You are required to complete the information below.  “Immediate family” is defined as a spouse, child, parent, and sibling; and the spouse’s child, parent and sibling.  Include those employed in all branches of state government: judicial, legislative, executive, higher education and state authorities; and those employed as regular or contract employees, or elected officials.  This "sunshine disclosure" is intended to ensure that the citizens of our Commonwealth have full confidence in their government and its hiring process.  The disclosure will not be used to exclude any qualified applicant seeking a position within the Executive Branch from receiving full consideration based on the merits of his/her credentials and the requirements of the job.  Attach additional pages if needed.

 

Name of Relative

Relationship

Title of Relative’s Job

State Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                       _____________________________   

Signature of Applicant Date

 

____________________________________________________

Printed Name