Municipal Prosecutor Separation Statement

Municipal Prosecutor Separation Statement
This form is served across protected 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate. This is the same level of protection used by online banking or e-commerce providers.
Section I. Personal Information
First Name*
Middle Name
Last Name*
Suffix
New Jersey Attorney ID*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Email Address*
example@example.com
Section II. Municipal Prosecutor Separation Information
Municipality*
County of Service*
Term of Appointment*

MonthDayYear
Begin Date
Date*

MonthDayYear
Date
MonthDayYear
End Date
Last Date of Employment as Municipal Prosecutor*

MonthDayYear
Date
Date of Notification to the Division of Criminal Justice*

MonthDayYear
Date
Section III. Certification & Online Filing Process
I hereby certify that this Municipal Prosecutor Separation Statement contains no willful misstatement of fact or omission of material fact and constitutes a full disclosure with respect to all matters required by New Jersey Attorney General Law Enforcement Directive 2019-7, to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to fines and possible disciplinary action.
Date*

MonthDayYear
Date
Signature*

Clear
I further certify that I intend my electronic signature on this statement to be the legally binding equivalent of my traditional handwritten signature.
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