Conflicts Form

Conflicts Form

I declare that I have read and understand the Arcus Conflicts of Interest Policy. I have disclosed all real, potential, or perceived conflicts of interest, and I agree to report any future conflicts immediately.
Your name:

First NameLast Name
Job title:
Today's date:

MonthDayYear
Date
I have perceived, or real conflicts with the following people:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
Name:
Their role:
I certify that, to the best of my knowledge, this is the extent of my conflicts.
Signature
Should be Empty: