Conflict of Interest Checklist
Please complete this checklist to disclose any personal, financial, or professional interests that may present a conflict with your organizational duties.
Full Name
*
First Name
Last Name
Position or Role in the Organization
*
Department/Unit
*
Do you have any close family members (spouse, partner, parent, child, sibling) who have business dealings with the organization?
*
Yes
No
Do you or your immediate family have any direct or indirect financial interests in any organization that does business with, seeks to do business with, or competes with this organization?
*
Yes
No
Are you currently engaged in any outside employment, consulting, or advisory roles that may relate to your duties here?
*
Yes
No
Have you participated in any procurement, contract, or hiring decisions involving organizations or individuals with whom you have a personal relationship?
*
Yes
No
Have you received any gifts, hospitality, or favors from any person or organization doing or seeking to do business with this organization in the past 12 months?
*
Yes
No
Are you currently involved in any legal proceedings or disputes that could impact your role or create a conflict of interest?
*
Yes
No
If you answered 'Yes' to any of the above, please provide details below.
Have you previously disclosed any conflicts of interest that are still ongoing?
*
Yes
No
Signature
*
Submit Checklist
Submit Checklist
Should be Empty: