Conflict of Interest Declaration
This form requires individuals to disclose details of any and all interests that are relevant that may be in conflict with their duties and responsibilities in a grant selection process.
In concept, a conflict of interest may exist if any person in his or her official duties or having any role or responsibility that may involve in deciding or selecting could draw a connection or affiliation. This may be due to the possibility of influence in the performance of his or her official duties that may be damaging to the trust and confidence of the public.
Please fill out this form as a manifestation that no conflict of interest exists in your position in the selection and decision for the grant to the applicants.
Name
First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
I hereby declare to the best of my knowledge that I:
Do not have any apparent interest whether real or personal, in the selection or awarding of grant to any of the applicants or grantee under the program Do not have any family members up to fourth civil degree, who are applicants, or its employees, with apparent interest whether real or personal. Do not have any personal business that may be in conflict of interest with the applicants for grant under the program Do not have in any way personal or real interest that may affect my duty or responsibility in selecting grantees or awardees in the program
Other Statements
Declare additional statements that are not part of, or exceptions above
I hereby likewise declare that I fully understand that in case any information that may cause me to be in a position that shall be in conflict of interest with regard to my duties and responsibilities arises after this declaration, I shall thereafter inform the Committee.
I shall abide by the rules and regulations set forth by the institution, including it any relevant rules and regulations, with regard to conflict(s) of interest.
I hereby declare under penalty of perjury that I make this conflict of interest declaration with the above details being true and correct to the best of my knowledge and in good faith.
Signature
Clear
Date signed
Month Day Year
Date
Should be Empty:

Conflict of Interest Declaration