Ethics Committee Action Request Form
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THE TOWN OF CENTREVILLE 101 LAWYERS ROW CENTREVILLE, MD 21617
410-758-1180 FAX 410-758-4741 WWW.TOWNOFCENTREVILLE.ORG
ETHICS COMMISSION ACTION REQUEST FORM
1. Are you: (cid:1) Filing a Complaint OR (cid:1) Requesting an Advisory Opinion
2. Type or Print Your Name:
Address:
Home Phone: Cell Phone:
Email Address:
3. Identify the individual(s) you are complaining about or requesting an advisory opinion on:
Name: Position/Title:
Address:
Home Phone: Cell Phone:
Email Address:
4. Explain in detail why you believe that the individual named above may have violated the Ethics Code or
the nature of your request for an advisory opinion.
5. Attach or make reference to any documents, materials, minutes, resolutions or other evidence which
support your allegations or request.
I swear or affirm, under penalty of perjury, that the facts set forth herein are true and correct to the best of my knowledge and belief.
Signature Notary Public My Commission Expires:
Seal:
W:\0-BOARDS AND COMMISSIONS\Ethics Commission\Ethics Inquiry Form.doc Rev. 7/27/16
THE TOWN OF CENTREVILLE 101 LAWYERS ROW CENTREVILLE, MD 21617
410-758-1180 FAX 410-758-4741 WWW.TOWNOFCENTREVILLE.ORG
INSTRUCTIONS:
1. Complete all sections of the complaint form. Incomplete forms will not be processed.
2. The Commission will not investigate complaints made anonymously.
3. Give the specific name and address (if known) of the person about whom you are complaining.
If you are complaining about more than one person, use a separate complaint form for each person. You may photocopy or reproduce this form if you need more forms.
4. Provide a detailed account of the activity that is alleged to be in violation of the Ethics Code.
The Commission’s jurisdiction extends solely to alleged violations of the Code of Ethics of the Town of Centreville. Please ensure that all allegations relate to specific individuals. If you are not sure that the Commission has jurisdiction over the conduct or individual in question, refer to the Town of Centreville’s Ethics Code or contact the Town office.
5. Enclose records, documents, minutes, etc, that support your allegations.
6. Sign the form and have a notary sign, date, and note the date their commission expires.
IMPORTANT:
Any person filing a complaint with the Town Ethics Commission should be aware of the provisions of the Town Ethics Code.
W:\0-BOARDS AND COMMISSIONS\Ethics Commission\Ethics Inquiry Form.doc Rev. 7/27/16