Who must complete the Employee Disclosure Form?

All persons making an application to a Town of Hempstead agency must answer the form’s two questions, sign and date it, and submit it with their application.

What information does the form ask for?

It asks whether the applicant or application owner is a Town employee, or whether an entity is more than five percent owned by a Town employee. It also requests the applicant’s name, signature, date, and nature of the application or consideration.

Do I need a notary for the Employee Disclosure Form?

No. The document is signed and dated without a notary and does not mention a notarized or sworn attachment or related step.

Hempstead, NY · Nassau County

No notary required

Employee Disclosure Form

Applicants to a Town of Hempstead agency use this form to disclose whether they or the application’s owner have a Town employee connection.

What this form is

The Town of Hempstead requires all people applying to a Town agency to answer two questions about whether the applicant or the owner is a Town employee or an entity partly owned by one. The form asks for yes-or-no answers, the applicant’s signature and date, printed name, and the nature of the application or consideration.

Who needs it

Anyone applying to a Town of Hempstead agency must complete and submit this disclosure form with their application.

How to submit it

Submit the signed and dated form with your application to the Town agency. The form lists the Department of Water at 1995 Prospect Avenue, East Meadow, NY 11554-3100.

About notarization

This document is signed and dated without a notary; it does not mention any notarized or sworn attachment or related step.

How to submit this form

1
Download The Form
Download the Town of Hempstead Employee Disclosure Form.
2
Answer The Questions
Answer both yes-or-no questions about Town employee connections.
3
Complete And Sign
Print your name, state the nature of the application or consideration, and sign and date the form.
4
Submit With Your Application
Submit the completed disclosure form with your application to the Town agency.

Frequently asked questions

Who must complete the Employee Disclosure Form?: All persons making an application to a Town of Hempstead agency must answer the form’s two questions, sign and date it, and submit it with their application.
What information does the form ask for?: It asks whether the applicant or application owner is a Town employee, or whether an entity is more than five percent owned by a Town employee. It also requests the applicant’s name, signature, date, and nature of the application or consideration.
Do I need a notary for the Employee Disclosure Form?: No. The document is signed and dated without a notary and does not mention a notarized or sworn attachment or related step.
How do I submit the Employee Disclosure Form?: Sign and date the form, then submit it with your application to the Town agency. The form lists the Department of Water address in East Meadow.

Need something notarized?

This Employee Disclosure Form doesn’t need a notary — but if you have another Hempstead form that does, a commissioned online notary can help.