2024 Conflict of Interest Disclosure

Name of Discloser*

First Last

Email Address for Discloser*

Enter Email Confirm Email

Are you a voting Director*

Yes
No

Are you an ISCD Officer*

Yes
No

If you are an Officer, which Officer Position do you hold:

President
President-Elect
Vice President
Treasurer
Secretary
Immediate Past-President
CEO/Executive Director

Are you a Key Employee?*

Yes
No

If you are a Key Employee, What position do you hold:

What other positions do you hold with ISCD (type N/A or None if applicable)*

By checking each box this will serve as your initials that each statement below is true:*

I have received a copy of the ISCD Conflict of Interest Policy.
I have read and understand the Conflict of Interest Policy.
I agree to comply with the Conflict of Interest Policy.
I understand ISCD is a non-profit 501(c)(3) organization and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes.

Disclosures:

(a) To the best of your knowledge, please list any entity of which you are a director, officer, member, owner (either as a sole proprietor or a partner), or employee and with which ISCD has a relationship and any transaction in which ISCD is a participant. (Type N/A or None if applicable)*

(b) Please describe any other relationships or matters that could give rise to a Conflict of Interest (as defined in the Conflict of Interest Policy). (Type N/A or None if applicable)*

I have read the Policy attached hereto and attest that the disclosures above are true and complete to the best of my knowledge.

NOTE: This form is to be signed by each Responsible Person upon initial election or appointment and at the end of every calendar year.

Conflict of Interest Policy

By checking this box and typing my name below, I am electronically signing my Conflict of Interest Disclosure Form:*

Electronically Signing

Full Name*

Date*

2024 Conflict of Interest Disclosure

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2024 Conflict of Interest Disclosure

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