Determined to Develop a Conflict of Interest Disclosure Form

1. Full Name

First NameLast Name

1a. E-mail

example@example.com

Please read the Determined to Develop Conflict of Interest Policy. (Click here for a printable copy).

2a. Are you a voting Director?

2b. Are you an Officer?

i. If you are an Officer, which Officer position do you hold?

3a. I affirm I have received a copy of the Determined to Develop Conflict of Interest Policy.

3a. Initial

3b. I have read and understand the policy.

3b. Initial

3c. I agree to comply with the policy.

3c. Initial

3d. I understand that DETERMINED TO DEVELOP is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of tax-exempt purposes.

3d. Initial

4a. Do you have a financial interest (current or potential), including a compensation arrangement, as defined in the Conflict of Interest policy with DETERMINED TO DEVELOP?

i. If yes, please describe it:

ii. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy?

4b. In the past, have you had a financial interest, including a compensation arrangement, as defined in the Conflict of Interest policy with DETERMINED TO DEVELOP?

i. If yes, please describe it, including when (approximately):

ii. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy?

5. Are you an independent director, as defined in the Conflict of Interest policy?

i. If you are not independent, why?

E-Signature:

Type your name to attest to the truth and accuracy of this form at time of submission. By pressing submit below your form will be time and date stamped accordingly.

Determined to Develop Conflict of Interest Disclosure

Position

Affirmations

Disclosures