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Part 1
* First Name:
Middle Initial:
* Last Name:
*Address Line 1:
Address Line 2:
* City:
* State:
*Zip Code:
* MD County:
* Email Address:
*Board/Commission Name:
(If you don't have a specific board name, please select the Department name that you may be interested in)
Selected Board/Department Names:
Part 2
* Exemption Requested:
* I request exemption for:
Financial Interest
* Name of Entity where the financial interest exists:
* Address Line 1 of Entity:
Address Line 2 of Entity:
* City:
* State:
* Zip:
* MD County:
* Interest to be Exempted:
* Current Value:
Employment
Employment to be Exempted:
* Your Position/Job Title:
* Explain below why you believe you may have financial interests or an employment situation that, in the absence of an exemption,
will conflict with your service on the board or commission for which appointment is being considered.
You may wish to contact the State Ethics Commission for information or advice at 410-260-7770.
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