* Required

Statement of Interest - Serving as Associate Member (non-voting) on Town Ad Hoc Committee

Please fill in the following personal information:


Please be advised that all town officials must comply with Section 1203 of the Town Charter-Conflict of Interest: "Any elected or appointed officer, any member of any board or commission, or any employee of the town who has a financial interest direct or indirect, in any contract, transaction or decision of any officer or agent of the town or any board or commission, shall disclose that interest to the Board of Selectmen for recording upon their official records and any such person shall be thereby disqualified from participation in the awarding, assignment or discussion of any contract, transaction, or decision. Violation of this provision shall be grounds for the removal of any such person." Should you be appointed to serve on a town board, commission or agency, you would be required to comply with these regulations.

By providing my electronic signature below I certify that I understand and accept Section 1203 of the Town of Ellington Charter and Attendance Policy (printed on back) and agree to abide by such.
By typing your electronic signature, you give permission for the Town of Ellington to authorize this as a signature.​