Directors and Officers Declaration Form
Please complete this declaration to confirm your eligibility and disclose any potential conflicts of interest as a director or officer.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Position/Title
*
Organization Name
*
Period of Service (Start Date)
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently serving as a director or officer in any other organization?
*
Yes
No
Do you have any personal, financial, or professional interests that could conflict with your duties?
*
Yes
No
Please list any potential conflicts of interest or state 'None'.
*
Have you ever been convicted of an offense or disqualified from acting as a director or officer?
*
Yes
No
By signing below, I declare that the information provided is true and complete to the best of my knowledge, and I agree to notify the organization of any changes.
*
Submit Declaration
Submit Declaration
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