policies/conflict-of-interest-policy/montana-dinosaur-center-director-and-officer-conflict-of-interest-statement.md

Montana Dinosaur Center Director & Officer Conflict of Interest Statement

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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:_____________________________.
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)
   Disclosures:
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
   1. If yes, please describe it: ____________________________________________
   2. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
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
   1. If yes, please describe it, including when (approximately): _______________________________________________
   2. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
5. Are you an independent director, as defined in the Conflict of Interest policy? Yes No
   • If you are not independent, why? ____________________________________________________________

Signature of Director______________________________________________________Date_______________________

Date of Review by Executive Committee: ____________________________________________________________