Name:
Position Title:
Department:
Circle one:
Yes No 1. Did you, in a private capacity, provide consulting, advisory or outreach services to an entity or persons outside the company that might, in your good faith judgment, present or appear to present a conflict of commitment with your company obligations (especially within the past twelve (12) months)?
Yes No 2. Did any of your immediate family members have an employment, consulting, or other financial relationship with (especially within the past twelve (12) months):
a) A company that does business with [Company name]?
b) An outside organization contributing gift funds to [Company Name] that are under your control or of direct benefit to your work activities?
Yes No 3. Did you or any members of your immediate family, acquired “significant financial interests*” (especially within the past twelve (12) months):
a) That directly affect or reasonably appear to affect your work or company business; or
b) In entities whose financial interests directly or reasonably appear to affect your work or company business.
*Significant financial interests: Financial interests valued in excess of $5,000 or which equal or exceed 5% ownership (i.e, as the actual or beneficial owner of more than five percent (5%) of the voting stock or controlling interest), for any one enterprise or entity when aggregated for you and your immediate family.
If you have answered “yes” to any of the above questions, please attach a statement identifying the entity or entities involved and a description of the relevant activities. Please describe any other relationships, commitments, or activities that you or any members of your immediate family have that might present or reasonably appear to present a financial conflict of interest in your employment with [Company Name].
NOTE: This form must be updated and submitted to Human Resources within 60 days of any change in status of financial interests (i.e. when financial interests in an entity increase to the $5,000/5% threshold) as well as provide an update annually.
Certification:
In signing and submitting this form, I certify that the above information is true to the best of my knowledge, and that I am in compliance, to the best of my knowledge, with federal law, state law and all company policies related to conflicts of interest.
Signature: Date:
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