Institutional Conflict of Interest Financial Disclosure Form

Institutional Conflict of Interest Financial Disclosure Form

Name:
Division/Department/Unit:

Questions

/ Yes / No
Outside Compensation
Do you, your spouse, domestic partner or dependents receive income from any source, outside of your employment at Binghamton University, which poses or may have the appearance of posing a conflict of interest? A Conflict of Interest may arise if your outside income may be influenced by any negotiations or agreements you make in your role with Binghamton University. Provide a short explanation of the circumstance for each Yes answer. /
/
Outside Affiliations
Do you, your spouse, domestic partner or dependent serve as an owner, officer, director, partner, employee, consultant or other designation in an outside organization that poses or may have the appearance of posing a conflict of interest? A Conflict of Interest may exist if you must act on the behalf of the outside organization in negotiations or agreements with Binghamton University. Provide a short explanation of the circumstance for each Yes answer. / /
Investments
Do you, your spouse, domestic partner, or dependent own individual stocks, stock options, bonds or real estate that poses or may have the appearance of posing a conflict of interest? A Conflict of interest may exist if you own real estate or more than $10,000 of an individual stock or five percent of a company where the value of your investment can be influenced by actions you take in your role at Binghamton University. Provide a short explanation of the circumstance for each Yes answer. / /
Institutional COI Certification
·  I have read the Institutional Conflict of Interest Policy Statement on Page 1.
·  I certify that the answers provided in this declaration are accurate and truthful to the best of my knowledge.
·  I agree to update this disclosure form if any answer to the above questions change.
Signature______Date______