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: ____________________________________________________________
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