Conflict of Interest Disclosure Form
Name:______________________________________________________________________________
Position/Title/Department: ________________________________________________________________
Date: __________________________
All CNM employees have an obligation to disclose or report situations or activities that create an actual,
potential, or apparent conflict of interest.
A. If this is a self-disclosure, please complete this section.
Briefly describe any interest, relationship, or transaction that could create a real, apparent, or potential
conflict of interest contrary to the requirements or general principles set forth in CNM’s Conflict of Interest
Policy:
Organization ________________________________________
Your Position ________________________________________
Nature of Business Relationship________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I have read CNM’s Conflict of Interest Policy. I understand and accept my obligation to disclose in a
timely fashion any interest that I, or my immediate family, might have in a proposed CNM transaction.
The above is an accurate and current statement of all my reportable outside interests and activities, to
the best of my knowledge.
________________________________________________________________________________
Employee Signature (Required for Self-disclosure)
Date
B. If you are reporting a suspected, witnessed, or known activity that may constitute a conflict of interest,
describe the activity in as much detail as possible below.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
(Use additional page for more information if necessary.)
(Hand deliver or mail this form in a sealed envelope to Director of Internal Audit.)