SAINT LOUIS UNIVERSITY by 8g4KEO

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									                                                                EXHIBIT III

                              SAINT LOUIS UNIVERSITY

            DISCLOSURE OF CERTAIN INTERESTS OF THE
CHIEF EXECUTIVE OFFICER, ADMINISTRATIVE STAFF MEMBERS, FACULTY
  MEMBERS WITH ADMINISTRATIVE RESPONSIBILITIES AND SELECTED
                           EMPLOYEES

Pursuant to the purposes and intent of the Administrative policies issued May 27, 1988
requiring disclosure of certain interests, a copy of which has been furnished to me, I
hereby state that I or members of my immediate family (as defined by the conflict of
interest policy) have taken part in the following transactions or activities that, when
considered in conjunction with my position with or relation to Saint Louis University,
might constitute a conflict of interest. (Check “None” were applicable.)

OUTSIDE ACTIVITIES OR INTERESTS

Identify any interests or activities of yourself or your immediate family in any outside
organizations or activities which may constitute a current or potential conflict of interest
as described in the conflict of interest policy.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
( ) None

OTHER

List any other activities in which you or your immediate family are engaged that might be
regarded as constituting a conflict of interest as defined by the conflict of interest policy.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
( ) None




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                                                               EXHIBIT III

GIFTS, GRATUITIES AND ENTERTAINMENT

I hereby certify that neither I nor any members of my immediate family have accepted
gifts, gratuities, or excessive entertainment from any concern conducting or seeking to
conduct business with Saint Louis University (as described in the gift policy) except as
listed below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
( ) None

I further agree to report to the appropriate administrative level any situations that may
develop during the coming year which may constitute an actual or potential conflict of
interest.

_________________________________            _____________________________
         (Print Name)                                 (Title)


            Department

_________________________________ _____________________________
         (Signature)                        (Date)




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