Employee Gift and Conflict of Interest Disclosure Form
Use this form to disclose any gifts, hospitality, outside relationships, secondary employment, vendor or customer relationships, or any actual, potential, or perceived conflict of interest.
Full Name
*
First Name
Last Name
Department or Team
*
Type of Disclosure
*
Please Select
Gift Received
Hospitality
Outside Relationship
Secondary Employment
Vendor/Customer Relationship
Actual Conflict of Interest
Potential Conflict of Interest
Perceived Conflict of Interest
Other
Please provide details about your disclosure
*
Date of Incident or Relationship Start
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name(s) of Involved Individual(s) or Organization(s)
Estimated Value (if applicable)
Have you previously disclosed this matter?
Yes
No
Additional Comments (optional)
I confirm that the information provided is accurate to the best of my knowledge.
*
I agree
Submit Disclosure
Should be Empty: