Disclosure of Interest under PM-67 [Contracts between the University and Faculty Members]; and
Recusal from participation in negotiation and decision making on behalf of LSU.
To:
Director, Office of Technology Management
LSU Health Sciences Center – New Orleans
433 Bolivar St., Suite 827
New Orleans, LA 70112
Part A
I/We, the undersigned, have formed/intend to form, or are otherwise involved in the following for-profit business (“Company”):Company Name: ______
Address: ______
Tel: ______Fax: ______E-Mail: ______
State of Incorporation: ______
Type of Corporation/Company: (C, S, LLC, LLP, Sole Proprietorship, Partnership, etc.): ______
This disclosure is made in partial fulfillment of the requirements of LSU’s Permanent Memorandum 67 governing contracts between Company and LSU. I/We LSU employee(s) agree to recuse myself/ourselves from participation in negotiation or decision making on behalf of LSU with respect to the proposed contract(s).
I/We, further agree to update the information contained in this disclosure promptly upon any change, if such change affects the status of the contract.
Signatures
Note: All LSU employees (including employees of LSU during the past two years) who have any role in the Company
(e.g., part or full ownership, officer / manager, director on the board, employee, consultant, etc.) must sign below:
______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______/ ______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______
______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______/ ______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______
______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______/ ______
Signature Date
Name: ______
Dept. ______
College: ______Campus: ______
Role in Company: ______
Part B: List ALL DIRECTORS on the Board of Company - whether or not they are also listed in Parts A, C or D.
{Attach additional sheets, as needed}
1.Name: ______Title in Company: ______Ownership % in Company: ______Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
2.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
3.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
4.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
5.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
Part C: List ALL OFFICERS / MANAGERS of Company - whether or not they are also listed in Parts A, B or D.
{Attach additional sheets, as needed}
1.Name: ______Title in Company: ______Ownership % in Company: ______Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
2.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
3.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
4.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
5.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
Part D: List ALL 10 % or GREATER SHAREHOLDERS / MEMBERS / OWNERS of Company - whether or not they are also listed in Parts A, B or C.
{Attach additional sheets, as needed}
1.Name: ______Title in Company: ______Ownership % in Company: ______Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
2.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
_
College: ______Campus: ______
3.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
4.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______
5.Name: ______Title in Company: ______Ownership % in Company: ______
Res. Address: ______
[A] Current LSU employee ? □ Yes □ No [B] Was LSU employee any time during past 2 years ? □ Yes □ No If Yes, Date resigned/retired from LSU: ______
If Yes, to [A] or [B] give full details of employment at LSU.
Title at LSU: ______Dept.: ______
College: ______Campus: ______