2.5 KiB
2.5 KiB
Conflict of Interest Statement
- 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:_____________________________.
- 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: - 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
- If yes, please describe it: ____________________________________________
- If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
- 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
- If yes, please describe it, including when (approximately): _______________________________________________
- If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy? Yes No
- 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: ____________________________________________________________