Annual Conflict of Interest Statement

Director Name Year

Disclosure of Potential Conflicts

List any relationships, positions, or circumstances that you or a family member have or may have that could give rise to an actual or potential conflict of interest with the organization: List any transactions or affiliations with any entity with which the organization does business that you or a family member may have:

Affirmation

I affirm the following:
1. I have received and read the organization's conflict of interest policy.
2. I agree to comply with the policy.
3. I will disclose any potential conflicts of interest as they arise, in accordance with the policy.