Atkinson Conflict of Interest Committee

PO Box 224

Atkinson, NH 03811- 0224

 

 

Part A PETITIONER INFORMATION FORM

Name:________________________________________ Address:_______________________________________

City:_______________________ State:__________ Home Phone:________________ Cell Phone:_______________

Business Name (if applicable):_______________________________________________________________________

BusinessAddress:__________________________________City:__________________________ State:____________

Business Telephone No:___________________________ Business Cell Phone No:__________________________

 

 

Part B Request for Information ONLY

I, undersigned, request that the Conflict of Interest Committee review and reply as to whether or not the details following constitute a violation of the Atkinson Conflict of Interest Ordinance. Give specific details regarding your request for information pertaining to Section V. of the Ordinance, page 4.______________________________________________ _______________________________________________________________________________________________________________________________________________________________________ Use back of page if necessary.

 

 

You must complete PART A, above. You shall be notified by mail of the of the finding / reply of the Conflict of Interest Committee.

 

I have read the Atkinson Conflict of Interest Ordinance and I believe this is a fair subject of inquiry.

Signature __________________________________________ Date: _____________________

 

 

Part C Petition of Alleged Conflict of Interest Violation I, undersigned, request that the Conflict of Interest Committee investigate whether or not the following action constitutes a violation of the Atkinson Conflict of Interest Ordinance. I specifically ask for an investigation of the following individual: _______________________________________who is a member of Atkinson town government (title of office held: _______________________________________) for the following reason: ___________________________________

_______________________________________________________________________________________________________________________________________________________________________ Use back of page if necessary.

 

 

You must complete PART A, above. You shall be notified by mail of the date that this petition will be included on the agenda for a meeting of the Conflict of Interest Committee and you may be asked to attend the meeting.

 

I have read the Atkinson Conflict of Interest Ordinance and I believe this is a fair subject of investigation.

Signature __________________________________________ Date: _____________________

Please mail this form to Conflict of Interest Committee, PO Box 224, Atkinson NH, 03811-0224 Request / Petition form- Rev. March 14, 2006

 

You must complete PART A, above. You shall be notified by mail of the date that this petition will be included on the agenda for a meeting of the Code of Ethics Committee and you may be asked to attend the meeting.

 

I have read the Atkinson Code of Ethics Ordinance and I believe this is a fair subject of investigation.

Signature __________________________________________ Date: _____________________

Please mail this form to Code of Ethics Committee, PO Box 224, Atkinson NH, 03811-0224 Request / Petition form- Rev. March 12, 2004