Conflict of Interest Form

Blount Library
Conflict of Interest Form

TO: President, Blount Library Board of Trustees

RE: Conflict of Interest Disclosure

A copy of the Blount Library Conflict of Interest Policy has been furnished to me. I hereby state that I, or members of my respective families or households, have the following affiliations or interest and have taken part in the following transactions that, when considered in conjunction with the position with or relation to the Blount Library, might possibly constitute a conflict of interest. (Check “None” where applicable)

1. Outside Interests     (   ) None

2. Outside Activities     (   ) None

3. Inside Information     (   ) None

4. Gifts, Gratuities, and Entertainment     (   ) None

5. Other     (   ) None

I hereby agree to report to the Board Chairperson any further situation that may develop before completion of my next questionnaire.

       Date            Name (Printed or typed) Signature