Conflict of Interest Disclosure By Member of Board of Directors

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					This is a disclosure statement made by a member of the board of directors of a
corporation that discloses all actual and potential conflicts of interest the board member
or their spouse has with the corporation. In the event of an actual conflict of interest, the
board member agrees to either correct the conflict or to refrain from participating in the
consideration and discussion of the conflicted issues. This document should be used by
board members of a company that wish to disclose any conflicts of interest they may
have with the corporation.
                       CONFLICT OF INTEREST DISCLOSURE
                                           of
                 _____________________ [Instruction: INSERT NAME],
                          a member of the board of directors of:
          ____________________ [Instruction: INSERT CORPORATION NAME]

                          Dated: ___________ [Instruction: Insert Date]

Having received and read a copy of the policy of ___________ [Instruction: Insert
Corporation Name] (the “Corporation”) regarding potential and actual conflicts of interests
regarding the members of the Corporation’s board of directors (the “Board”), and myself being a
member of the Board, I hereby make the following statements. Each of the below statements
include the ownership and/or acts of my spouse, any of my or my spouse’s relatives who live in
the same house with me, and/or any trust or estate in which my spouse or I have a beneficial
interest or serves as trustee or fiduciary. I will promptly notify the Corporation, if, after the date
of this statement, I acquire any interest or engage in any activity which would have to be
disclosed as an exception to any of the below statements. In the event that any of my statements
present an actual conflict of interest with the interests of the Corporation, I will either: correct the
conflict (to the extent possible) or recuse myself from the consideration and discussion of all
such conflicted issues.

1. I have no holdings or dealings in interests in properties or rights which are the same or
similar to the properties and rights used in the business of the Corporation, except as follows:
___________ [Instruction: Insert conflict, if applicable]

2. I have accepted no commissions, fees or other forms of remuneration, borrowed money
(except bona fide loans from established financial institutions) or accepted gifts or favors of
significant value from any person or firm with whom the Corporation does or is likely to do
business or with whom the Corporation competes, except as follows: ___________ [Instruction:
Insert conflict, if applicable]

3. I have had no speculation or dealing in materials, supplies, products, equipment or property
of any kind that is or may be purchased or sold by the Corporation, except as follows:
___________ [Instruction: Insert conflict, if applicable]

4. I have made no purchase or lease of real estate or other facilities which the Corporation may
be interested in, or may need in the future, except as follows: ___________ [Instruction: Insert
conflict, if applicable]

5. I am not participating in any outside activity for profit, except as follows: ___________
[Instruction: Insert conflict, if applicable

6. I am not participating in any other outside activity which may interfere with my efficiency in
performing my function as a member of the Board, may cause public criticism or may result in
revealing confidential Corporation information, except as follows: ___________ [Instruction:
Insert conflict, if applicable]
7. I am not directly or indirectly engaged in and do not hold a financial interest in any
organization, business enterprise or professional organization other than (a) checking and savings
accounts, (b) ownership of stock in a mutual fund and/or (c) the ownership of less than 1% of
any class of securities listed on a National Securities Exchange or traded in a recognized major
market, except as follows: ___________ [Instruction: Insert conflict, if applicable]

                                             Very Truly Yours,


                                             ________________________________
                                             [Instruction: sign]
                                             ________________________________
                                             [Instruction: Insert Name of Signatory], Director

				
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Description: This is a disclosure statement made by a member of the board of directors of a corporation that discloses all actual and potential conflicts of interest the board member or their spouse has with the corporation. In the event of an actual conflict of interest, the board member agrees to either correct the conflict or to refrain from participating in the consideration and discussion of the conflicted issues. This document should be used by board members of a company that wish to disclose any conflicts of interest they may have with the corporation.