CONFLICT OF INTEREST STATEMENT  

Date: *

Name: *

Position (employee/volunteer/trustee): *

Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest between Dominican Association of Tampa,Inc. and your personal interests, financial or otherwise: : *

I have no conflict of interest to report : *

I have the following conflict of interest to report (please specify other nonprofit and for-profit boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own): : *

In addition to my service for Dominican Association of Tampa,Inc , at this time I am a Board member or an employee of the following organizations: : *

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed, and agree to abide by, the Policy of Conflict of Interest of Dominican Association of Tampa,Inc . : *

Submit