Cfgrb Disclosure Statement For Conflict Of Interest Policy, Confidentiality And Privacy Policy And Code Of Ethics And Conduct Policy Form Page 2

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Please initial in the space at the end of Item A or complete Item B (whichever is appropriate). Then complete Item
C, and sign and date the statement and return it to CFGRB staff.
A. I am not aware of any relationship, interest or situation involving myself or an Immediate Family Member that
might result in, or give the appearance of being, a Conflict of Interest. _________________ (Initials)
B. The following are relationships, interests or situations involving me or an Immediate Family Member that I
consider might result in, or appear to be, an actual, apparent or potential Conflict of Interest.
If an item relates to an Immediate Family Member, please provide his or her name and the type of relationship
(e.g. spouse), in addition to describing the relevant circumstances.
• For-profit corporate directorships, positions and employment:
Self
Immediate Family Member ___________________________
Name of Organization(s) _________________________________________
• Nonprofit boards or trusteeships:
Self
Immediate Family Member ___________________________
Name of Nonprofit(s) ____________________________________________
• Memberships in the following organizations:
Self
Immediate Family Member ___________________________
Name of Organization(s) _________________________________________
• Contracts, business activities and investments with or in the following organizations:
Self
Immediate Family Member ___________________________
Name of Activities ______________________________________________
• Other relationships and activities:
Self
Immediate Family Member ___________________________
Names _______________________________________________________
C. My primary business or occupation at this time:
I have read and understand CFGRB’s Conflict of Interest Policy, Code of Ethic and Conduct and Confidentiality
and Privacy Policy and agree to be bound by it. I will promptly inform the board chair of CFGRB of any material
change that develops in the information contained in this disclosure statement.
___________________________
__________________________
__________________
Type/Print Name
Signature
Date
Updated 1/7/16

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