Conflict of Interest Disclosure Form
Name
Date
Position/Title
Organization
1. Are you or any of your family members affiliated with an entity that does business with this organization?
2. Please describe any potential conflicts of interest involved:
3. Do you or your family members have a financial interest in any business or organization that does business with this organization?
4. Please describe any other situations that may be seen as a conflict of interest:
Signature
Date