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Policy Number: 01.002a Policy Title: Annual Conflict of Interest Disclosure Form Policy Type: Board Policy Governing Body: Board of Trustees Annual Conflict of Interest Disclosure Form Purple: Employees and members of the Board of Trustees complete this form annually to help the College identity and resolve conflicts of interest in the organization. A conflict of interest may exist when an employee or a Board member is involved in any activity, or has a personal or financial interest, that may interfere in the performance of his or her duties, or his or her objectivity in performing those duties. Name: ______________________________ Position: _______________________ 1. Are you employed by, do you serve on the board of directors of, or do you perform any work or provide any services as an independent contractor, agent or consultant for, any business or other entity (profit of non-profit) that (a) does business in any capacity with (vendor, supplier, customer, partner, etc.) (b) sells the same or substantially similar products or services as, or (c) competes in any way with, Antioch College? Circle one: Yes or No If you answer “Yes” state: a) The name and address or the organization(s):__________________________ __________________________________________________________________ b) Your position(s): _________________________________________ c) Whether you have referred business Antioch College to the organization(s): Circle one: Yes or No d) Whether you have referred business from the organization to Antioch College: Circle one: Yes or No 2. Do you have a financial interest in any other entity that (a) does business in any capacity with, or (b) competes in any way with Antioch College? Circle one: Yes or No If you answer “Yes” state: a) The name and address or the organization(s) _________________________ _____________________________________________________________ b) What your financial interest is in the organization(s): ________________ ________________________________________________________ c) Whether you own more than one-tenth of one percent of the organization(s): Circle one: Yes or No
d) Whether you have referred business from Antioch College to the organization(s): Circle one: Yes or No e) Whether the organization has referred business to Antioch College through you: Circle one: Yes or No 3. Do you have any relatives or family members who work as an employee, an independent contractor or otherwise for, serve on the board of directors of, or have a financial interest in, any entity (profit or non-profit) that (a) does business in any capacity with, or (b) competes in any way Antioch College? Circle one: Yes or No If you answer “Yes” state: a) The name(s) of the relative(s) and your relationship to such person: b) The name and address of the organization(s) with which associated: c) The relative(s) or family member(s) position(s) with the organization(s): d) The relatives(s) or family member(s) financial interest in the organization(s): e) Whether you have referred business to the organization(s): Circle one: Yes or No f) Whether the relative or family member has referred business to Antioch College: Circle one: Yes or No 4. Has any current or prospective vendor, supplier, or customer of Antioch College, or any other entity that does or has sought to do business with Antioch College, provided you with, or assumed on your behalf the cost of, goods or services of any kind whose value exceeds $25.00 as a gift or other perquisite? Circle one: Yes or No If you answer “Yes” state: a) The name of the person who provided you with, or assumed the cost of, such goods and/or services and the business entity with which such person is associated: b) The goods and/or services you received, their estimated value and when you received them: ________________________________________________________________________________________________________________________________________________
5. In your capacity with the College, have you hired or retained, as an employee, an independent contractor or otherwise, or do you supervise, and family member or other relatives? Circle one: Yes or No If you answer “Yes” state: a) The name of the family member(s) or other relative(s) and your relationship to such person(s): 6. Are you involved in any public service or charitable organizations to which Antioch College contributes or whose actives may be in conflict with those or Antioch College? Circle one: Yes or No If you answer “Yes” state: a) Describe the activity and/or relationship: ____________________________ Signature: ____________________ Date:__________________ Please complete this form and return it to the Business Office. Thank you.
