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Nsf Form 1230a - Confidential Conflict-Of-Interest Statement For Nsf Advisory Committee Members - National Science Foundation

National Science Foundation

Alexandria, VA 22314

Confidential Conflict-of-Interest Statement for NSF Advisory Committee Members

Name of Advisory Committee:

In carrying out your duties as a member of an NSF advisory committee, you will be called upon to give advice on NSF policy

deliberations. We do not anticipate that you will ordinarily participate in any "particular matter". However, sometimes policy

deliberations focus on the interests of specific persons or organizations or on a discrete class of specific persons or entities. In such

cases, your personal financial interests or your affiliations or relationships with other affected persons or entities may raise conflict-

of-interest questions. By providing the information requested on this form, you will satisfy a requirement of U.S. Office of

Government Ethics regulations and help the Foundation identify and resolve potential (and apparent) conflicts. You must return

your completed statement to the NSF official responsible for the Committee before your serve on the Committee.

For each of the three parts below list all interests, positions, arrangements, or relationships you think might reasonably be

responsive. If you have none, check the "NONE" box.

Part 1: Financial Interests

If you, your spouse, or your dependent children hold any stock, securities, or similar financial interests in any nongovernmental

entity that could be affected by any NSF policy deliberation likely to come before the Committee - list all such holdings.

[EXAMPLE: Does your spouse hold stock in a computer company that could be affected by a change in NSF's standards for

NONE

funding computer centers?]

(Identify specific business, stock, bond, etc.)

Nsf Form 1230a - Confidential Conflict-Of-Interest Statement For Nsf Advisory Committee Members - National Science Foundation