Conflict of Interest Disclosure Statement Form
CONFLICT OF INTEREST DISCLOSURE STATEMENT FORM
The DISCLOSURE STATEMENT is confidential and will be available to the Nominations Committee and WOCN Board of Directors. Statements will be kept at the WOCN Society Office.
Please respond to the following questions:
1. Do you or your business currently maintain any type of financial relationship (excluding stock ownership of publicly traded companies), agreement, employment, investment (other than stock ownership of publicly traded companies), consultation, contract, grant or any other type of arrangement - either verbal or written - with an individual or organization which does business with the WOCN Society, may do business with the WOCN Society, or provides products or services to the clientele which is served by the membership of the WOCN Society?
Please list the names of those individuals and organizations, the type of services you provide, and your approximate yearly income from these services.
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2. In the past year have you or your business provided any services, on an ad hoc basis, to an individual ororganization, which does business with the WOCN Society, may do business with the WOCN Society, or provides products or services to the clientele, which is served by the membership of the WOCN Society?
Please list the names of those individuals or organizations, the types of services you provided, and yourapproximate yearly income from these services.
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- In the past year have you or your business received any gifts (monetary or otherwise) or entertainment totaling more than $500 from any individuals or organizations which do business or may do business with the WOCN Society or provide products or services to the clientele which is served by the membership of the WOCN Society?
Please list, for the previous year, the names of those organizations or individuals and the giftsor amountsreceived.
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As a potential or current Board/Council Member or Board appointed person of the WOCN Society, I understand that I have an ongoing affirmative duty to bring to the attention of the WOCN Society Board of Directors any situation which may be an actual, potential or questionable conflict of interest, and I will report promptly to the Board of Directors any future situation out of which a possible conflict of interest might arise. The information I have given in this statement is complete and accurate, to the best of my knowledge. I will update this DISCLOSURE STATEMENT yearly or whenever there are any substantive additions or deletions to be made to it.
Name (print) ______
Signature ______
Date______