Conflict of Interest Disclosure Statement

Conflict of Interest Disclosure Statement
In order to be more comprehensive, this statement of disclosure/questionnaire also requires you to provide information with respect to certain parties that are related to you. These persons are termed “affiliated persons” and include the following:
1. your spouse, domestic partner, child, mother, father, brother or sister;
2. any corporation or organization of which you are a board member, an officer, a partner, participate in management or are employed by, or are, directly or indirectly, a debt holder or the beneficial owner of any class of equity securities; and
3. any trust or other estate in which you have a substantial beneficial interest or as to which you serve as a trustee or in a similar capacity.
1. Name:*

First NameLast Name
2. Select the Board/Commission/Committee you are serving on:*

Board of DirectorsFoundation Board of DirectorsAccreditation CommissionCertification CommissionProfessional Ethics CommissionPsychotherapy CommissionAdvocacy CommitteeAnti-Bias Work GroupCurriculum CommitteeFinance CommitteeInternational Relations CommitteeLeadership Development CommitteeProfessional Well-being CommitteeResearch CommitteeStaff
3. Have you or any of your affiliated persons provided services or property to ACPE in the past year?*

YesNo
If yes, please describe the nature of the services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
4. Have you or any of your affiliated persons purchased services or property from ACPE in the past year?*

YesNo
If yes, please describe the purchased services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
5. Please indicate whether you or any of your affiliated persons had any direct or indirect interest in any business transaction(s) in the past year to which ACPE was or is a party.*

YesNo
If yes, describe the transaction(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
6. Were you or any of your affiliated persons indebted to pay money to ACPE at any time in the past year (other than travel advances or the like)?*

YesNo
If yes, please describe the indebtedness and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
7. In the past year, did you or any of your affiliated persons receive, or become entitled to receive, directly or indirectly, any personal benefits from ACPE or as a result of your relationship with ACPE, that in the aggregate could be valued in excess of $1,000, that were not or will not be compensation directly related to your duties to ACPE?*

YesNo
If yes, please describe the benefit(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
8. Are you or any of your affiliated persons a party to or have an interest in any pending legal proceedings involving ACPE?*

YesNo
If yes, please describe the proceeding(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
9. Are you aware of any other events, transactions, arrangements or other situations that have occurred or may occur in the future that you believe should be examined by ACPE’s Board in accordance with the terms and intent of ACPE’s conflict of interest policy?*

YesNo
If yes, please describe the situation(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
I herby confirm that I have read and understand ACPE’s conflict of interest policy and that my responses to the above questions are complete and correct to the best of my information and belief. I agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this policy, I will notify the appropriate ACPE officer immediately.
Signature (Click and hold your mouse button to sign. Or if using a touchscreen, use your finger to sign):*

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