Disclosure Form

4.) Have you or an immediate family member accepted gifts, gratuities, lodging, dining, or entertainment that might reasonably appear to influence your judgment or actions concerning the business of the Council? *

Yes

No

If yes...please provide details below:

Name *

If yes...please provide details below:

3.) Do you or does any member of your immediate family have a financial or personal interest in an entity in which the Council has a financial or other vested interest? *

Yes

No

1.) Are you or a member of your immediate family an officer, director, trustee, partner (general or limited), employee or a regularly retained consultant of any company, firm or organization that presently has business dealings with the Council or which might reasonably be expected to have business dealings with the Council in the coming year? *

Yes

No

If YES...please list the name of the company, firm, or organization, the position held, and the nature of the business which is currently being conducted with the Council or which may reasonably be expected to be conducted with the Council in the coming year:

5.) Do you have any other interest or role in a firm or organization, where that interest or relationship might reasonably be expected to create an impression or suspicion among the public having knowledge of your acts that you engaged in conduct in violation of your trust as a trustee, officer, or staff member? *

Yes

No

Acknowledgement: Conflict of Interest – Board Member Affirmation and Disclosure Statement: *

My answers to this disclosure form are correctly stated to the best of my knowledge and belief. Should a possible conflict of interest arise in my responsibilities to the Council, I recognize that I have the obligation to notify, based on my position, the appropriate designated individual (Chair of the Council and/or Executive Director), and to abstain from any participation in the matter unless and until the Council can determine whether a conflict exists and how that conflict shall be resolved. If any relevant changes occur in my affiliations, duties, or financial circumstances, I recognize that I have a continuing obligation to file an amended “Conflict of Interest Disclosure Form” with the appropriate designated office.

If yes... please list the name of the company, firm or organization, the nature of the interest and the name of the person holding the interest, and the nature of the business which is currently being conducted with or which may reasonably be expected to be conducted with the Council in the coming year:

Acknowledgement: Conflict of Interest – Board Member Affirmation and Disclosure Statement: *

I understand that the information on this form is solely for use by the Council and is considered confidential information. Release of this information within the Council will be on a need-to-know basis only. Release to external parties will be only when required by law and/or federal regulations.

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Date and time *

If yes...please provide details below:

2.) Do you or does any member of your immediate family have a financial interest, direct or indirect, in a company, firm or organization which currently has business dealings with the Council or which may reasonably be expected to have such business dealings with the Council in the coming year? *

Yes

No