Sample Conflict of Interest Acknowledgement and Identification Form

YOUR CHURCH NAME GOES HERE

Conflict of Interest Acknowledgement and Identification Form

Name:__________________________________________________________

(Printed)

Position within the Church_____________________________________________

(Printed)

Please describe below any relationships, positions, or circumstances in which you are involved that you believe could contribute to a Conflict of Interest (as defined in Your Church Name Church Policy on Conflicts of Interest) arising.

1.________________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

4.________________________________________________________________

5.________________________________________________________________

Should you require more line items, attach them as a separate addendum to this form.

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed, and agree to abide by, the Policy of Conflict of Interest of (your church name goes here) that is currently in effect and on record with the corporate documents. This policy can be obtained and reviewed via a direct request to the Secretary of the corporation.

 

Signature: ____________________________     Date: _____________________

Witness:   ­­­­­­­­­­­­­­­­­­­­­­­____________________________     Date: ­­­­­­­­­­­­­­­­­_____________________