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6 <br />ORANGE COUNTY SENIOR STAFF <br />DISCLOSURE STATEMENT <br />Please answer all questions and where your answer is none or not applicable so state. ANSWERS SHOULD BE <br />PRINTED OR TYPED, and additional sheets may be used if more space is needed. For clarification of any question <br />please refer to the County Attorney. Upon its completion this Disclosure Statement shall be filed with the Human <br />Resources Department on or before December 31 of each calendar year. <br />Note: The failure to file this Disclosure Statement is a violation of the Orange County Ethics and Conduct for <br />Senior Staff Policy and may subject you to disciplinary action. <br />1 <br />NAME OF OFFICIAL (LAST) (FIRST) (INITIAL) TITLE <br />2. Department <br />Appointed Department Director on <br />3. I have completed the required one hour of ethics training _Yes _ No. If Yes, please attach description and <br />location of course taken. If No, please state the date you last completed ethics training <br />4. Provide a general description and location of property you own in Orange County. <br />5. List the name and address of any business, profit or non-profit, or organization that has solicited, or is currently <br />soliciting, the award of a bid or any other approval from Orange County within the past 12 months and with which you or <br />your spouse or domestic partner or your child are associated as that phrase is defined in the Senior Staff Ethics Policy. <br />Name/Address of Business --- Position <br />If the position with the company is occupied by a spouse, domestic partner or child so state. <br />This Disclosure Statement is true and the information contained herein accurate as of the below date: <br />SIGNATURE <br />DATE: <br />For Use by the Human Resources Department <br />Date Received Received by (initial) <br />