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Conflict of Interest Disclosure Form A potential or actual conflict of interest exists when commitments and/or obligations are likely to be compromised by the board or commission member(s)’ other material interests, or relationships (especially economic), particularly if those interests or commitments are not disclosed. This Conflict of Interest Form should indicate whether the board or commission member(s) has an economic interest in, or acts as an officer or director or, any outside entity whose financial interests would reasonably appear to be affected by the addition of the nominated condition to the board or commission. The member(s) should also disclose any personal, business, or volunteer affiliations that may give rise to a real or apparent conflict of interest. Individuals with a conflict of interest should refrain from any involvement in decision making related to the topic. Date: __________________ Name: _______________________________________ Board/Commission Name: __________________________________ Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I hereby certify that the information set forth above is true and complete to the best of my knowledge. Signature: _____________________________________________ Date: _______________________