Conflict of Interest Disclosure Form

Also See ANA Conflict of Interest Policy

Name *

First

Middle

Last

Email *

May use ANA official email address if currently a Board Member

Position *

1► Additionally, as an employee or member of the Board of Directors or the Employee Review Team, I realize that I have an obligation to disclose and eliminate (if necessary) any potential or actual duality of interest or conflict of interest. *

I Agree

2► The term “relationship” means any relation with a person or organization, whether financial (such as a significant donation of more than $100), employment (such as a volunteer assignment, part-time job or as a consultant or independent contractor) or fiduciary (such as a board member or officer). The term “immediate family” means spouse, parent, children or other individual living in the same household. *

I Understand

3► Below, I have listed all organizations, for-profit corporations, non-profit corporations or charitable programs that I, or a member of my immediate family, have a relationship with, that have sought or may in the future seek to do business with the American Naprapathic Association (ANA). **Please list on below. You may separate with a comma or press enter for additional lines** *

May also write N/A if there are no conflicts to report at this time...

3► *Section for additional space if necessary.

Signature *

4►I hereby certify that I have read, understand and agree to the American Naprapathic Association policies as described in this statement, with respect to confidential information and conflict of interest, and that the information given in this statement is complete and accurate to the best of my knowledge.

Date of disclosure *

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