Conflict of Interest Form

SOUTH CENTRAL REGION TEACHERS ASSOCIATION BOARD OF DIRECTORS

CONFLICT OF INTEREST POLICY AND CONFIDENTIALITY AGREEMENT

 ANNUAL DISCLOSURE FORM

 

  1. INTRODUCTION:  I have read and I understand the SCRTA Conflict of Interest Policy.  I agree to act consistent with that Policy, to promote the best interests of SCRTA and to avoid actual or perceived conflicts of interest when making decisions and taking actions that may affect SCRTA.
  2. FINANCIAL OR NON-FINANCIAL BENEFIT:  To the extent that I now have, or have had during the past 12 months, or may foreseeably have in the next 12 months, a financial or non-financial benefit as described in SCRTA’s Conflict of Interest Policy, I disclose below:  (a) the nature of the financial or non-financial benefit; (b) the name of the involved entity, and; (c) a description of the activity sufficient for the SCRTA Board of Directors to determine whether there is or may reasonably be a perceived conflict of interest.
  3. OTHER RELATIONSHIPS:  I also will disclose any other direct or indirect business, investment, professional, personal or family relationship during the past 12 months or foreseeable during the next 12 months that might influence, or might be reasonably perceived by others to influence, my judgment or actions related to SCRTA.
  4. PROMPT DISCLOSURES AND UPDATES;  It is my duty to disclose potential conflicts to SCRTA as soon as possible and, whenever possible, in advance of assuming any position or entering any transaction that might cause the conflict.  I agree to update this information promptly if circumstances change, without waiting for SCRTA to submit to me a new annual disclosure form.
  5. UNCERTAINTY:  I agree that whenever I am in doubt as to whether a past, current, or foreseeable activity requires disclosure, I will disclose it promptly to SCRTA.
  6. CONFIDENTIALITY:  During my SCRTA service, I will have access to confidential information.  I agree not to disclose that information or use it in any way other than for SCRTA’s benefit and purposes.

 

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Print Name                                                          Signature

 

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