This form is intended to help the organization identify and address conflicts of interest. All consultants must complete this disclosure form at the start of their engagement and update it as needed.

Consultant Name Email Address Date

Disclosure of Actual or Potential Conflicts

Please disclose any personal, professional, or financial relationships, positions, or circumstances that might be viewed as a conflict of interest (including relationships with vendors, donors, or other organizations).

Describe all actual or potential conflicts of interest:

Steps to Address Conflicts (if any)

If applicable, describe any steps taken to manage or eliminate the potential conflict(s):

I have no conflicts of interest to disclose at this time.