Annual Conflict Disclosure Statement

This form is to be completed annually by all staff members in accordance with the organization's conflict of interest policy.

Staff Name

Position/Title

Date

Annual Conflict Disclosure

Please disclose any actual or potential conflicts of interest, including relationships with vendors, organizations, family members, or other interests that may influence your decisions or actions on behalf of the organization:

If you have nothing to disclose, please type "None" in the space above.

By signing below, I certify that I have read and understand the conflict of interest policy and have disclosed all potential conflicts.

Signature