Vendor Due Diligence - Conflict Of Interest Certification Statement Form

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Northwestern University
Vendor Due Diligence – Conflict of Interest Certification Statement
The following questionnaire needs to be completed by the individual(s) who selected or directed the vendor to be added to
NUFinancials.
It is the policy of Northwestern University that its employees conduct the affairs of the University in accordance with the highest
ethical, legal and moral standards. An employee must not be in a position to make a decision for the University if his or her
personal, professional, or economic interests may be directly influenced or affected by the outcome.
Please complete the following questionnaire as it relates to your relationship or activities with the proposed vendor. A “Yes” answer
does not necessarily constitute a conflict of interest. However, without complete disclosure, a fair and reasonable assessment of
whether this vendor is an appropriate business partner of the University cannot be made. If you answer “Yes” to a question, please
use the comment box to describe the potential conflict of interest. The form must also be reviewed and approved by the individual
that approves your annual Conflict of Interest form (COI Manager).
Proposed Vendor Name:_________________________________________________
To the best of your knowledge:
YES
NO
Comments
Are you or an immediate family member or extended
family member (e.g. spouse, child, sibling, parent, niece,
nephew, or in-law) employed by , acting as a consultant,
or have a financial interest in the company?
Have you or an immediate family member or extended
family member received any gifts (other than
promotional items or an occasional meal) or more than
incidental hospitality from the new vendor within the last
12 months?
Have you or an immediate family member or extended
family member given a gift or provided more than
incidental hospitality to the proposed vendor within the
last 12 months?
Individual submitting the form via the NUPortal: _____________________________________________
Signature:_________________________________________________ Date: ______________________
Individual (s) who selected or directed the vendor to be added to NUFinancials:
_____________________________________________
Signature:_________________________________________________ Date: ______________________
If an individual has answered “Yes” to one of the above questions, the COI Manager must review and approve the form.
COI manager:
_____________________________________________
Signature:_________________________________________________ Date: ______________________
Updated: April 10, 2012
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