DISCLOSURE FORM FOR TRUSTEES
Please complete the following:
1. Are you aware of any relationships with the University between yourself or a member of your family as defined by the letter or spirit of these standards that may represent a conflict of interest? Yes No If YES , please list or elaborate about such relationships and the details of actual or potential financial benefit as you can best estimate them.
2. Did you or a member of your family receive, during the past 12 months, any gifts or loans from any source from which the University buys goods or services or otherwise has significant business dealings? Yes No If YES , please list such loans or gifts, their source, and their approximate value.
I certify that the foregoing information is true and complete to the best of my knowledge.
Signature
Name (please print):
Date:
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