Sample Conflict of Interest Policy

Apr 28, 2017 | Board Meeting Tools

SAMPLE POLICY                                                                                                                                    For the Fiscal Year Ended _____

 

Conflict of Interest Policy

 

 INSTRUCTIONS:  Please answer the following questions, sign the agreement below and return to the association office.  Thank you.

  1. Do you (or a member of your family) have, directly or indirectly, an employment, consultant or volunteer position with, or a material interest in any entity with which our organization does business, proposes to do business, or could reasonably be expected to do business?

No

Yes

 

If yes, please list the entities and describe the nature of the relationship.

 

 

  1. Do you (or a member of your family) have, directly or indirectly, an employment, consultant or volunteer position with, or a Material Interest in any entity which provides advice to a competitor and/or competes, plans to compete, or could reasonably be expected to compete with our organization (and/or its affiliates) in the purchase, sale or delivery of any property or property right, interest, goods or services?

No

Yes

 

If yes, please list the entities and describe the nature of the relationship.

 

 

  1. During the past 12 months, have you (or a member of your family) solicited or accepted a payment, gift, meal, entertainment, service or other benefit from any person or entity that does or is seeking to do business with our organization?

No

Yes

 

If yes, please describe.

 

 

  1. Have you (or a member of your family) used the name, image, service/trademarks or confidential and/or strategic information of our organization, affiliates or their resources or property, in connection with any commercial or other interest or activity not associated with our organization?

No

Yes

 

If yes, please describe the use. 

 

 

I have read and agree to comply with the current Conflicts and Confidentiality Policy. My signature below also acknowledges my understanding that I have a duty to supplement the information I have provided, if such information changes prior to the next annual request for information, or if I become aware of a situation in which the possibility of a conflict of interest may exist.

 

Print Name: _________________________________   Position: __________________________

 

Signature: ___________________________________  Date:  ____________________________

 

Please return this document to: