Conflict of Interest Disclosure Form

Procurement Committee Member

Name:

Position/Title:

Committee Name:

Procurement/Project Title:

Disclosure of Conflict of Interest:

I declare that I have no actual, potential, or perceived conflict of interest in relation to this procurement. I have actual, potential, or perceived conflict(s) of interest to disclose (provide details below).

If conflict exists, describe the nature and extent (including relationships, interests or circumstances):

Mitigation Plan (if applicable):

Signature:

Date: