Conflict of Interest Policy Form Conflict of Interest Policy 1. Are you aware of any relationship between ISSOTL and yourself or a member of your family as defined by the letter or spirit of this policy that may represent a conflict of interest or the appearance of a conflict of interest? Yes No If yes, please list such relationships and the details of annual or potential benefit as you can best estimate them. 2. During the past 12 months, did you or a member of your family receive any gifts, compensation, services, materials, entertainment, or loans from any source from which ISSOTL purchases goods or services, or otherwise has significant business dealings? (Gifts, compensation, services, materials, or entertainment that are occasional and reasonably modest (i.e. less than $200 in value) are excluded from this policy.) Yes No If yes, please list the item(s), the source, and the approximate value. I certify that I have read and understand the CONFLICT OF INTEREST AND ANNUAL DISCLOSURE POLICY and that the foregoing information is true and complete to the best of my knowledge. * I certify that I have read and understand the CONFLICT OF INTEREST AND ANNUAL DISCLOSURE POLICY and that the foregoing information is true and complete to the best of my knowledge. Last Name Last Name First Name First Name If you are human, leave this field blank. Submit
