Conflict of Interest Disclosure Statement

Refer to Conflict of Interest Policy (ADM-P008)

REMINDER: If at any time there is a matter under consideration that may constitute a direct or indirect conflict of interest or duality of interest, it is your obligation to disclose the facts to the Committee, to abstain from voting and to refrain from using your personal influence on the matter.

*Avocation: an activity taken up in addition to one’s regular work or profession, often for enjoyment, a hobby

FORM HR-113 (Effective 8.1.17)

Conflice of Interest Form

Leave Blank

Name

First Name

Last Name

Current employer of other principal business affiliation

Position

Other Business or Avocational Interests

Please disclose any other employment or financial interest which you or a member of your immediately family may have as either an officer, director, trustee, partner, employee or agent of any business organization, which might give a rise to a possible conflict of interest or duality of interest with the Hospice of the North Country.

Charitable or Civic Involvement

Please disclose all official positions which you or any member of your immediate family may have as a director, trustee or officer of any charitable, civic or community organization as well as any unofficial roles such as significant donor, volunteer, advocate or advisor which might give rise to a possible conflict of interest or duality of interest between you and the Hospice of the North Country.

Electronic Signature

Typing your name serves as a written signature

Date

YYYY

Conflict of Interest Disclosure Statement

Listen. Comfort. Serve.

Plattsburgh Office

Malone Office

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