WASHBURN UNIVERSITY

ANNUAL CONFLICT OF INTEREST DISCLOSURE STATEMENT







I have read the Washburn University Conflict of Interest Policy and understand its provisions, and hereby provide the following information (attach additional pages as necessary):





1. List all current places of employment (or those held during the last twelve months), and any businesses from which you, your firm, or your family to the third degree of consanguinity received $2,000 or more in compensation (salary, director fees, thing of value, or economic benefit received in return for services rendered, or to be rendered), which was reportable as taxable income on your federal income tax returns (if none, write "None"):





Business Name and Address Position Held Held by Whom




2. List any organization or business in which you, your firm, or your family to the third degree of consanguinity currently serve (or have served during the last twelve months) as a member, director, trustee, officer or agent of or for the organization or business, irrespective of the amount of compensation received for holding such position (if none, write "None"):





Business Name and Address Position Held Held by Whom




3. List any corporation, partnership, proprietorship, trust, joint venture and every other business interest including land used for income, in which either you, your firm or your family to the third degree of consanguinity currently owns (or has owned during the last twelve months) a legal or equitable interest exceeding 5%. If you, your firm, or your family to the third degree of consanguinity own more than 5% of a business, you must disclose the percentage held (if none, write "None").





Business Name and Address
Type of Business Description of Interests Held Ownership Interest % Held by Whom




4. List any stocks, mutual funds or retirement accounts in which you, your firm, or your family to the third degree of consanguinity currently owns(or has owned during the last twelve months) more than 5% of the entity (if none, write "None"):





Business Name and Address Ownership Interest % Held by Whom




5. List any person or business from whom you, your firm, or your family to the third degree of consanguinity either individually or collectively, have received gifts or honoraria having an aggregate value of $500 or more in the preceding twelve months (if none, write "None").





Name of Business or Person Address Received by:


DECLARATION:





I, _______________________________, declare that this conflict of interest disclosure (including any accompanying pages and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of all my economic interests and other matters required by the conflict of interest policy.









___________________ ______________________________________

Date Signature





Return your completed statement to the Office of University Counsel.






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