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ArtsQuest Board Governance Manual

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CONFLICTS OF INTEREST STATEMENT<br />

AND ACKNOWLEDGEMENT<br />

This is to certify that I have been presented with a copy of the <strong>ArtsQuest</strong> Conflicts of Interest Guidelines of and<br />

that I have read them, understand them and agree to follow the guidelines outlined therein.<br />

I am not aware of any relationship or interest or situation involving my family or myself that might result in, or<br />

give the appearance of being, a conflict of interest between my family member and/or myself on one hand and<br />

<strong>ArtsQuest</strong> on the other. Initials_____<br />

Or<br />

The following are relationships, interests, or situations involving me or a member of my family that I consider<br />

might result in or appear to be an actual, apparent, or potential conflict of interest between my family member<br />

and/or myself on one hand and <strong>ArtsQuest</strong> on the other. Initials_____<br />

Corporate (either non-profit or for-profit) directorships, positions, and employment:<br />

Memberships in the following organizations:<br />

Contracts, business activities, and investment(s) with or in the following organizations:<br />

Other relationship or activities:<br />

My primary business or occupation at this time is:<br />

I shall advise my <strong>Board</strong> or Committee Chair, Manager, Sr. Leadership, Finance or Human Resources of any<br />

relationship that may arise in the future that should be disclosed.<br />

Signature of Acknowledgement Name (please print) Date<br />

PLEASE ACKNOWLEDGE RECEIPT AND ACCEPTANCE OF THESE GUIDELINES BY SIGNING THIS FORM AND<br />

RETURNING IT TO HUMAN RESOURCES, JOANN LEE OR COURTNEY ANGLE.<br />

THANK YOU<br />

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