Fill and Sign the Conflict of Interest Form Links

Conflict of Interest Form Name of Employee or Board Member: ______________________________________________________________ Position: Board of Directors Executive Committee Officer Committee Member Staff position: Have you or any of your family members provided services or property to the following this year: _____________________________________________________________________________________________ ___ Yes ___ No If the answer is yes, please describe the nature of the services or property that was provided: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have you or any family member of yours purchased services or property from _______________________________ in the past year? ___ Yes ___ No If the answer is yes, please describe the nature of the services or property that was purchased: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please indicate if you or any of your family members have had any direct or indirect interest in any business transactions in the past year where __________________________ was an interested party? ___ Yes ___ No If the answer is yes, please describe the nature of the business transaction: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Were you or any of your family members indebted to pay money to ______________________________________ At any time in the past year? ___ Yes ___ No If the answer is yes, please describe the nature of the indebtedness: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ In the past year have you or any member of your family become entitled to receive any personal benefits from _________________________________ or as a result of your relationship with ____________________________ that an aggregate amount of more than $1,000 that was not a result of compensation was given to you by _________________________________ that was not directly related to your duties? ___ Yes ___ No If the answer is yes, please describe the nature of the benefit: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Are you or any of your family members involved with any legal proceeding involving _________________________ ___ Yes ___ No If the answer is yes, please describe the nature of the services or property that was provided: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ I hereby confirm that I have read and fully understand _________________________________ Conflict of Interest Policy and my responses found above are complete and correct to the best of my belief and knowledge. I agree that if I become aware of any information that may indicate that there were incorrect disclosures made above that I will notify the above listed company immediately. Signature: ___________________________________________________________________ Date: ___/___/_____ State of: __________________________ County of: ________________________ The foregoing document was acknowledged before me this _________________ day of ______________________ 20_____, at _____________________________________ in the State of: _________________________________ By: __________________________________________________________________________________________ To be his or her free act of deed. Signature of Notary Public: _______________________________________________________________________ My commission expires: ___/___/_____ SEAL