SIGN IN   |   CONTACT   |   JOIN
Conflict of Interest Form
Share |

 

Thank you for volunteering with ACPM. In order to maintain the highest level of transparency within in the organization, we ask all volunteers complete a conflict of interest form that discloses ALL potential conflicts.  We also ask volunteers to read, understand and comply to ACPM's conflict on interest policy.

Do you, or any of your extended relations (spouse, significant other or dependent children ), have any material financial interests with any company or organization doing business with (i.e., providing goods, funding, or services to) the College? If Yes, please describe any business or related relationships during the statement period. Only describe a material holding if your financial ownership interest is 5% or more of your total wealth, or $10,000, whichever is less.


1000 of 1000 characters remaining
Do you, or any of your extended relations (spouse, significant other or dependent children), have a personal interest in a legal claim against the College or one of the Board members or staff members? If Yes, please describe such interest below.


1000 of 1000 characters remaining
During the current statement period (or prior period if this is your initial disclosure), did you, or any of your extended relations (spouse, significant other or dependent children) or any business or association with whom you are associated, receive compensation from the American College of Preventive Medicine (ACPM) for services rendered as an employee, independent contractor or otherwise? If Yes, please describe below.


1000 of 1000 characters remaining
During the statement period did you serve on the board or participate in a committee of any organization or corporation that conducts business or provides services to the College? If Yes, please list the organization, describe its business relationship with the College, indicate your role with the organization, and describe any potential competing or conflicting interest if applicable.
1000 of 1000 characters remaining
During the statement period, did you or any of your extended relations (spouse, significant other or dependent children) offer, solicit, or accept any gift, money, benefit, loan, or other payment of any kind valued at more than $50 from any entity with whom the College does business or is considering doing business? If Yes, list the gift, the person or entity from/to whom it was received/given/solicited, and its total estimated value.
I have read the American College of Preventive Medicine’s Conflict-of-Interest Policy, understand it, and agree to comply with its requirements during and, where applicable, beyond my current tenure. I also understand that identifying and disclosing any potential conflicts of interest are ongoing obligations during my time of service to the College. I certify that the representations made in this disclosure statement are true and complete to the best of my knowledge. I recognize that any material omissions or misleading statements may result in my requirement to resign any position I may hold at ACPM.

Membership Software Powered by YourMembership.com®  ::  Legal