Conflict of Interest Disclosure Form

Name: Position/Role: Date:

Disclosure of Potential Conflicts

Do you or a related party have a financial or personal interest in an entity with which our organization does business? Yes No If yes, please describe: Do you hold any position as an officer, director, trustee, partner, employee, or consultant for any third party that does business with our organization? Yes No If yes, please describe: Are there any other potential conflicts of interest you wish to disclose?

Certification

I certify that the above information is true and complete to the best of my knowledge. I agree to comply with the organization’s conflict of interest policy and will update this disclosure as needed.