CONFLICTS OF INTEREST DECLARATION & DISCLOSURE STATEMENT

Name: ________________________________ NSU ID: _______________________________

I have read the University's Conflict of Interest - Declaration & Disclosure Policy and I agree to comply with its provisions. I also affirm that my answer to the following question is true and correct to the best of my knowledge. I understand that any intentional omission or misrepresentation of information on this form may result in disciplinary action up to and including termination.

If the answer to this question is yes, describe below or on an attached sheet.

Are you aware of any actual or possible conflict of interest involving you or a closely-related family member? If yes, please describe (e.g., serve on the board of directors, or have a significant personal interest in a supplier, or contractor, describe fully the interest and any transactions between such entity and the University of which you are aware). No Yes

If yes, describe/explain here:

Signature Date

INSTRUCTIONS FOR SUBMISSION: Complete, print and sign form. Forward completed form to the Office of Human Resources located in the Horvitz Administration building on the main campus .