Executive Team Conflict Disclosure

1. Executive Information

Full Name Title/Role

2. Date of Disclosure

Date

3. Describe the Potential Conflict

Please provide details of the potential or actual conflict of interest.

4. Relationship or Interest

Explain your relationship or interest related to this conflict.

5. Steps Taken to Mitigate

Describe any steps you have taken or propose to take to mitigate or address the conflict.

6. Signature

Signature Date