Conflict of Interest Disclosure Form
for Board Members
Date
Name of Board Member
Position/Title
Disclosure of Possible Conflict of Interest
Please describe any relationships, positions, or circumstances in which you are involved that you believe could contribute to a conflict of interest between your personal interests and the interests of the organization:
If none, please type "None":
If you have relationships to disclose, please identify all persons, organizations, businesses, and the nature of your relationship(s):
Actions to avoid, manage, or resolve the conflict (if any):
By signing below, I affirm that I have read and understand the organization’s conflict of interest policy and that the foregoing information is complete and accurate to the best of my knowledge.
Signature
Date