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• ` ` ,,wF 4 I CODE OF ETHICS
4( TRAINING ACKNOWLEDGEMENT
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Honesty-Integrity-Character
Legal Name: \<e.V l rl Do +e r V O I (Please print clearly)
Employee Identification Number: 7(0$-2't— 7318
Agency/Municipality: 'Rork-01) Bc„gc.in Dept/Board: Elicc.4ion youth
By signing this acknowledgement, I am attesting that I have done the following:
[df Read the Palm Beach County Code of Ethics Ordinance (Ctrl+Click to follow link)
AND
Have completed additional training by viewing one of the following:
[4 The Code of Ethics Training Program on the Intranet/Internet. (Ctrl+Click to follow link)
[ ] The Code of Ethics Training Program on YouTube. (Ctrl+Click to follow link) •
[ ] The Code of Ethics Training Program on DVD.
[ ] A live presentation given on , 20_
I understand that I am responsible for understanding and abiding by the Palm Beach
County Code of Ethics as I conduct my assigned duties during my term of employment.
I also understand that the information in this policy is subject to change. Policy changes
will be communicated to me by my supervisor or through official notices.-
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(Legal Signature) (Date)
f.; Taliatitg_ Migreklad-IPAY7 "3,
Advisory Board Members: Submit signed forms to Appropriate Advisory Board Representative
PLEASE SUBMIT THIS FORM TO APROPRIATE PARTY AS HIGHLIGHTED ABOVE
PLEASE DO NOT SUBMIT THIS FORM TO THE COMMISSION ON ETHICS
300 North Dixie Highway,Suite 450,West Palm Beach,FL 33401
PHONE: 561.355-1915 FAX: 561.355-1904
Hotline: 877.766.5920 E-mail: ethics@palmbeachcountyethics.com
Website: www.palmbeachcountyethics.com
Rev.01/2017
The City of Boynton Beach Revised 12/2018
City of Boynton Beach
GST Y o 3301 Quantum Blvd.
Boynton Beach,Florida 33426
t' Phone:(561)742-6275 I Fax (561)742-6274
T°N a Request for Exemption from Public Records
In accordance with Section 119.071,Florida Statutes,certain records of employees,their spouses,and their children,are exempt from
disclosure of public records,if so requested.To ensure that records that are exempt from disclosure are properly identified,please follow
the steps outlined in this document.
STEP I.Review the Categories listed below.If applicable,check the category(s)that apply:
El Active or former sworn or civilian law enforcement personnel,including correctional and correctional probation officers,personnel of
the Department of Children and Families whose duties include the investigation of abuse,neglect,exploitation,fraud,theft,or other
criminal activities,personnel of the Department of Health whose duties are to support the investigation of child abuse or neglect,and
personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or
child support enforcement.
❑Firefighters certified in compliance with s.633.408. _ _ _ _ ___ _ _
❑Current or former justices of the Supreme Court,district court of appeal judges,circuit court judges,and county court judges.
❑Current or former state attorneys,assistant state attorneys,statewide prosecutors,or assistant statewide prosecutors.
❑General magistrates,special magistrates,judges of compensation claims,administrative law judges of the Division of Administrative
Hearings,and child support enforcement hearing officers.
❑Current or former human resource,labor relations,or employee relations directors,assistant directors,managers,or assistant managers
of any local government agency or water management district whose duties include hiring and firing employees,labor contract
negotiation,administration,or other personnel-related duties.
0 Current or former code enforcement officers.
❑Current or former guardians ad litem,as defined in s.39.820.
❑Current or former juvenile probation officers,juvenile probation supervisors,detention superintendents,assistant detention
superintendents,juvenile justice detention officers I and II,juvenile justice detention officer supervisors,juvenile justice residential
officers,juvenile justice residential officer supervisors I and II,juvenile justice counselors,juvenile justice counselor supervisors,
human services counselor administrators,senior human services counselor administrators,rehabilitation therapists,and social services
counselors of the Department of Juvenile Justice.
❑Current or former public defenders,assistant public defenders,criminal conflict and civil regional counsel,and assistant criminal
conflict and civil regional counsel.
❑Current or former investigators or inspectors of the Department of Business and Professional Regulation.
❑County tax collectors.
❑Servicemember(current or former member of the Armed Forced of the United States,a reserve component of the Armed Forces of the
United States,or the National Guard,who served after September 11,2011).
STEP IL Provide then`ames(s)of your spouse and/or children and-the reason they should-be exempt(see-categories above).-- - —
My spouse and/or dependent child named below belong in the category(s)that I have checked above.I understand that it is my
responsibility to inform the Human Resources and Risk Management Department immediately,should there be a change in the
status of my spouse and/or dependent child listed or not listed below.
(I)Name of sponse or child (1)Indicate category listed above (4)Name of spouse or child (4)Indicate category listed above
(2)Name of spouse or child (2)Indicate category listed above (5)Name of spouse or child (5)Indicate category listed above
(3)Name of spouse or child (3)Indicate category listed above (6)Name of spouse or child (6)Indicate category listed above
STEP III.Print your name,sign,and date the form. .
K.e;tin Du4er VG-1 ,--61---- 9/9/iq
Employee Printed Name Employee# Signature Date
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