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Please list on the form only those substantive relationships that you or members of your family maintain with
Organizations that do business with the University or that otherwise could be construed to potentially affect your independent, unbiased judgment in light of your decision-making authority or responsibility. 

First Name
  1. Are you aware of any relationships with the University between yourself and a member of your family, as defined by the letter or spirit of this policy that may represent a conflict of interest?  Yes      No

    If yes, please list or elaborate such relationships and the details of annual or potential financial benefit as you can best estimate them.

  2. During the past twelve months, did you or a member of your family receive any gifts (cash or property) with a total value of $1,000 or more from a vendor or contractor which has significant business dealings with the University? Yes      No

    If yes, please list such gifts here.

    Name of Source   Item Approximate Value

I affirm that: I have received a copy of the University’s conflict of interest policy; I have read and I understand the policy; I agree to comply with the policy; and I understand the University is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. This disclosure form is true and complete to the best of my knowledge.





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