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Director and Officer Annual Conflict of Interest Statement
Name
*
First
Last
Date
*
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
*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
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