Financial Conflict Of Interest And Disclosure Form
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1Financial Conflict of Interest
And Disclosure Form
Employee Name: ______________________________________________________________
The above mentioned employee hereby certifies that they have no affiliation with or financial
involvement in any entity that has direct financial interest in the business relationships of ACME
Publishing except as disclosed in an attachment. Please check the appropriate box of this form.
Do you have any conflict of interest or financial involvement with ACME Publishing?
[__] NO
[__] Yes, explanation attached
_______________________________________
Signature
_______________________________________
Print Name
____/____/______
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