20 lines
2.5 KiB
Markdown
20 lines
2.5 KiB
Markdown
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# Conflict of Interest Statement
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[Also available digitally](https://forms.monday.com/forms/9501dd91aed9008061d31455fc6cf45a?r=use1)
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1. Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Are you a member in Good Standing? Yes No What organization or other membership affiliation do you represent? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Position: Are you a voting Director? Yes No Are you an Officer? Yes No If you are an Officer, which Officer position do you hold:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
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2. I affirm the following: I have received a copy of the TMDC Conflict of Interest Policy. \_\_\_\_\_\_\_\_\_ (initial) I have read and understand the policy. \_\_\_\_\_\_\_\_\_ (initial) I agree to comply with the policy. \_\_\_\_\_\_\_\_\_ (initial) I have reviewed the Board Member Job Description. \_\_\_\_\_\_\_\_\_ (initial) I understand that TMDC 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. \_\_\_\_\_\_\_\_\_ (initial)\
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Disclosures:
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3. Do you have a financial interest (current or potential), including a compensation arrangement, as defined in the Conflict of Interest policy with TMDC? Yes No
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1. If yes, please describe it: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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2. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
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4. In the past, have you had a financial interest, including a compensation arrangement, as defined in the Conflict of Interest policy with TMDC? Yes No
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1. If yes, please describe it, including when (approximately): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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2. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
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5. Are you an independent director, as defined in the Conflict of Interest policy? Yes No
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* If you are not independent, why? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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Signature of Director\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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Date of Review by Executive Committee: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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