Conflict of Interest Disclosure

Conflict of Interest Disclosure
Company Name requires its to make full and accurate disclosure of any actual, potential, or perceived conflicts of interests related to their duties or responsibilities.
A conflict of interest may arise when an individual's personal, financial, professional, or other interests conflict with their duties to Company Name .
This form is intended to collect disclosures of any actual, potential, or perceived conflicts of interest that may relate to an individual's role, duties, or decision-making
Please briefly describe any personal, business, financial interest, activities or other interests that are potentially conflicts of interest.
Name
First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / 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 programDo 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 programDo 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.
Date signed
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Date
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