Director and Officer Annual Conflict of Interest Statement

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Position:
Are you a voting Director?*
- Yes
- No
Are you an Officer?*
- Yes
- No
If you are an Officer, which Officer position do you hold:
I affirm the following:
I have received a copy of the SourcePoint Conflict of Interest Policy.*
- Yes
- No
I have read and understand the policy.*
- Yes
- No
I agree to comply with the policy.*
- Yes
- No
I understand that SourcePoint, Inc. is a charitable organization and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more tax exempt purposes.*
- Yes
- No
Disclosures:
1. Do you have a financial interest (current or potential), including compensation arrangement, as defined in SourcePoint’s Conflict of Interest Policy?*
- Yes
- No
1a. If yes, please describe it:
1b. If yes, has the financial interest been disclosed, as provided in SourcePoint’s Conflict of Interest Policy?
- Yes
- No
2. In the past, have you had a financial interest, including a compensation arrangement, as defined in SourcePoint’s Conflict of Interest Policy?*
- Yes
- No
2a. If yes, please describe it, including when (approximately):
2b. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest Policy?
- Yes
- No
3. Do you have any special connections that could impose a conflict of interest or an appearance of a conflict of interest?*
- Yes
- No
3a. If you answered yes, please explain:
4. Are you an independent director, as defined in the Conflict of Interest Policy?*
- Yes
- No
4a. If you are not independent, why?
Signature of Director*
By typing your name above, this will be considered a digital signature.
Date*
Date Format: MM slash DD slash YYYY
Name
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Director and Officer Annual Conflict of Interest Statement

Position:

I affirm the following:

Disclosures:

Start typing and press enter to search