Independence and Objectivity Statement
Please complete this form to formally declare your independence and objectivity regarding the specified assignment or engagement.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Department
*
Position or Role
*
Assignment/Project Name
*
Assignment/Project Reference Number (if applicable)
Supervisor or Reviewer Name
Have you, or any immediate family member, had any financial or personal relationships that could present a conflict of interest with respect to this assignment?
*
No, I have no known conflicts of interest to declare.
Yes, I have a potential conflict of interest (please explain below).
If you answered 'Yes' above, please provide details of the potential conflict of interest.
Additional Comments (optional)
Date of Declaration
*
-
Month
-
Day
Year
Date
Signature
*
Submit Statement
Submit Statement
Should be Empty: