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3� ® PALM BEACH COUNT
• �I CODE OF ETHICS
9f TRAINING ACKNOWLEDGEMENT
eFACH LO
Honesty-ha grity-Character
Legal Name: �14ENE7_1�Em
U_ (Please print clearly)
Employee Identification Number:
Agency/Municipality: t\4y1Q Q/ADept/Board: LDUCA_7YON4of
VI ?
By signing this acknowledgement, I am attesting that I have done the following:
Viead the Palm Beach County Code of Ethics Ordinance (Ctrl+Click to follow linkt
AND
Have completed additional training by viewing one of the following:
[ ] 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.
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.
P i 3i
2p 12,91
(Legal Signature) (Date)
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.conn
Website: www.laalmbeachcountvethics.com
Rev.01/2017
suis ® _
Ile City of Boynton Beach
2018
City of Boynton Beach
3301 QuantumBlvd.
Boynton eac ,Florida 33426
Phone:(561)742-6275 : (561)742-6274
Request for Exemption from Public Records
In accordance with Section 119.071,Florida s,certain records of employees, spouses, eir children, e exempt from
disclosure of public records,if so requested.To ensure that records that are exempt from disclosuree properly identified, 1 e follow
e steps outlined in this document.
Review a Categories listed below. applicable,check the category(s) at apply:
❑tic 'v r former swom or civilian law enforcement perso el,including correctional and correctional probation officers,personnel of
e Department of Children es whose duties include the investigation o e,neglect,exploitation,fim4 theft,or other
criminal °vides,personnel of the Department of Healthwhose duties are to supporteinvestigation o child or neglect,and
personnel of the Department of Revenue or local governments hose responsibilities include revenue collection and enforcement or
child support enforcement.
certified compliance with s.633.409.
ElCurrent or formerjustices of the Supreme Coct court of appeal judges,circuit courtjudges,and county courtjudges.
ElCurrent or former state attorneys,assistant state attorneys,s to a prosecutors,or assistant statewide pros u .
El General magistrates,special magistrates,judges of compensation claims,administrative law judges of the Division of Administrative
Hearings,and child support enforcement officers.
Current or former human resource,labor relations,or employee relations ,assistant directors,managers,or assistant managers
of any local governmenta cy or water management district whose duties include ' ' employees, r contract
negotiation, s do or other personnel-related duties.
Current or former code enforcement officers.
ElCurrent or former guardiansad litern,as defined in s.39.820.
former11 Current or juvenile probation officers,j v e probation supervisors, 'on superintendents,assistant detention
juvenile justice detention officers I and 11,juvenile justice detention officer e ,juvenile justice residential
officers,juvenile justice residential officer supervisorsI and II,juvenile Justice counselors,juv a justice counselor supervisors,
human services counselor administrators,senior human services counselor administrators,re tion therapists,and social services
counselors of the Department of Juvenile Justice.
or former public defenders,assistant public defenders,criminal ict and civil regional counsel,and assistant
conflict civil regional counsel.
El Current or former investigators or inspectors of the Department of Business and ProfessionalRegulation.
OCounty tax collectors.
11 Servicemember(current or former member of the Armed Forced of the United States,a reserve component of the Armed Forces of the
United ,or the Nationalwho served after September 119 2011).
STEP IL Provide the names(s)of your spouse or children e reason they should be exempt(see categoriesabove).
My spouse and/ordependent childnamed belowel a category(s)that I have checked above.I understand that it is my
so I 'i o Resources RiskManagement Department immediately,should ere a c e
status of my spouse or dependent child s or not listed below.
(I)Name ofa or o ` _ (1)Indicate category -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 listve (6)Name of spouse or child (6)Indicate categrny listed above
STEP IM Print a i , a e a —
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