Conflict of Interest Disclosure Form

Name:

Department/Unit:

Position/Title:

Email:

Do you or any immediate family members have a financial or personal interest in any organization that does business with the university?

If yes, please provide details:

Are there any other relationships or situations that may present a potential conflict of interest?

If yes, please describe:

Certification:

I certify that the information provided is true and complete to the best of my knowledge.