CPRS Conflict of Interest Disclosure Form - California Park ...

California Park & RecreationSociety7971 Freeport Blvd., Sacramento, CA 95832Conflict of Interest Mandatory Statement of DisclosureThe CPRS Board of Directors has a Conflict of Interest policy that requires the State Board of Directors, District andSection Board of Directors, Regents, Committee and Task Force Chairs, and Staff to complete a MandatoryStatement of Disclosure by May 31 st each year. This form covers your current year of leadership service which mayhave begun prior to May 31st. This form shall be retained by CPRS during the individual’s term plus one year andmay be reviewed by a CPRS member if requested in writing to CPRS Executive Director, jane@cprs.org, 7971Freeport Blvd., Sacramento, CA 95832. The CPRS Conflict of Interest Policy is available at www.cprs.orgDirections: This form is to be completed annually no later than 31 May. You may complete the form on line; save acopy to your computer; and then email a copy to CPRS Headquarters to janet@cprs.org. You may also print out theform and fax a completed copy to CPRS, 916.665.9149. By typing in your name at the end of the form, you areacknowledging signing the form as you would with your signature.Date Completed Month Date YearFor the Leadership Year 20Name (Last) (First) (Middle)Office/Position(Check appropriate box and add title; President, Secretary, Member at Large, etc.)State Board (Title)District Board (Title)Section Board (Title)Committee (Title)Task Force (Title)Regent (Title)Other (Title)Employee (Title)EmployerJob TitleEmail AddressAs a member of the State Board of Directors, a District or Section Board of Directors, either appointed or elected; aCommittee/Task Force Chair, or Regent Board, serving as a volunteer working on behalf or at the behest of CPRS,or employee, I understand that I am obligated to disclose the existence of any facts or circumstances that mayconstitute a conflict of interest, as the term is defined in the CPRS Conflict of Interest Policy.By checking this box, I completed the Mandatory Statement of Disclosure in _________ (year) and nothinghas changed since my last submitted report. (Please date and sign/type your signature to this form on page 2 andreturn it to CPRS via email or fax.)

NameI have the following interests in third parties providing goods or services to CPRS and/or the parks and recreationprofession:I serve in a leadership capacity, have a significant investment, or own at least one percent in the following entitiesor organizations that may have conflicting interests with those of CPRS that may benefit either materially orotherwise due to my affiliation with CPRS, or take public positions contrary to those of CPRS:I expect to receive compensation from CPRS in the following amount, not including reimbursement of reasonableexpenses:The following members of my family expect to receive some form of compensation or material financial benefit fromCPRS:Outside of my capacity as a State, District, Section officer, chair, or employee of CPRS, I have a family relationshipor business relationship with the following directors, officers or key employees of CPRS:I wish to disclose the following additional facts or circumstances:By checking this box I have read and understand the CPRS Conflict of Interest Policy in full, andunderstand that I am required to notify the State Board in the event of any material change to the answers I haveprovided in this statement.By checking this box I agree to comply with the CPRS Conflict of Interest Policy.(Signature OR Typed Name)