Conflict of Interest Disclosure Form
This form is intended for members of the Board of Directors to disclose any actual or potential conflicts of interest.
Name
Board Title/Role
Date
1. Relationships and Interests
Please list any relationships, positions, or circumstances which you believe could contribute to a conflict of interest:
2. Outside Activities
Please disclose any outside activities, interests, or investments you or your immediate family have that may conflict with the interests of the organization:
3. Financial Interests
Please disclose any financial interests in entities that may do business with the organization:
4. Affirmation
I affirm that the information provided above is accurate and complete to the best of my knowledge.
Signature
Date