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Conflict of Interest
If there is a possible conflict of interest with a new employee please have them fill out and sign the attached form as soon as possible. After the form is filled out have the legal department review it and sign off on it as well. This is for both the company's and employee's protection.

Free Sample Template
Format: Word PDF
# of Pages: 3
Printable: Yes

Conflict of Interest TemplateForm 3427
Format: Word PDF
Category: Employee, Hiring
Type: Form

Conflict of Interest Form

Name of Employee or Board Member: ______________________________________________________________

Position:

Board of Directors

Executive Committee

Officer

Committee Member

Staff position:

Have you or any of your family members provided services or property to the following this year:

_____________________________________________________________________________________________

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was provided:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Have you or any family member of yours purchased services or property from _______________________________ in the past year?

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was purchased:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please indicate if you or any of your family members have had any direct or indirect interest in any business transactions in the past year where __________________________ was an interested party?

___ Yes ___ No




If the answer is yes, please describe the nature of the business transaction:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Were you or any of your family members indebted to pay money to ______________________________________

At any time in the past year?

___ Yes ___ No

If the answer is yes, please describe the nature of the indebtedness:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

In the past year have you or any member of your family become entitled to receive any personal benefits from _________________________________ or as a result of your relationship with ____________________________

that an aggregate amount of more than $1,000 that was not a result of compensation was given to you by _________________________________ that was not directly related to your duties?

___ Yes ___ No

If the answer is yes, please describe the nature of the benefit:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you or any of your family members involved with any legal proceeding involving _________________________

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was provided:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________




I hereby confirm that I have read and fully understand _________________________________ Conflict of Interest Policy and my responses found above are complete and correct to the best of my belief and knowledge. I agree that if I become aware of any information that may indicate that there were incorrect disclosures made above that I will notify the above listed company immediately.

Signature: ___________________________________________________________________ Date: ___/___/_____

State of: __________________________

County of: ________________________

The foregoing document was acknowledged before me this _________________ day of ______________________

20_____, at _____________________________________ in the State of: _________________________________

By: __________________________________________________________________________________________

To be his or her free act of deed.

Signature of Notary Public: _______________________________________________________________________

My commission expires: ___/___/_____

SEAL