Conflict of Interest Form

Name of Employee or Board Member: ______________________________________________________________

Position:

Have you or any of your family members provided services or property to the following this year:

_____________________________________________________________________________________________

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was provided:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Have you or any family member of yours purchased services or property from _______________________________ in the past year?

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was purchased:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please indicate if you or any of your family members have had any direct or indirect interest in any business transactions in the past year where __________________________ was an interested party?

___ Yes ___ No

If the answer is yes, please describe the nature of the business transaction:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Were you or any of your family members indebted to pay money to ______________________________________

At any time in the past year?

___ Yes ___ No

If the answer is yes, please describe the nature of the indebtedness:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

In the past year have you or any member of your family become entitled to receive any personal benefits from _________________________________ or as a result of your relationship with ____________________________

that an aggregate amount of more than $1,000 that was not a result of compensation was given to you by _________________________________ that was not directly related to your duties?

___ Yes ___ No

If the answer is yes, please describe the nature of the benefit:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Are you or any of your family members involved with any legal proceeding involving _________________________

___ Yes ___ No

If the answer is yes, please describe the nature of the services or property that was provided:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I hereby confirm that I have read and fully understand _________________________________ Conflict of Interest Policy and my responses found above are complete and correct to the best of my belief and knowledge. I agree that if I become aware of any information that may indicate that there were incorrect disclosures made above that I will notify the above listed company immediately.

Signature: ___________________________________________________________________ Date: ___/___/_____

State of: __________________________

County of: ________________________

The foregoing document was acknowledged before me this _________________ day of ______________________

20_____, at _____________________________________ in the State of: _________________________________

By: __________________________________________________________________________________________

To be his or her free act of deed.

Signature of Notary Public: _______________________________________________________________________

My commission expires: ___/___/_____

SEAL