2024/25 RID6270 Conflict of Interest Form

2024/25 Conflict of Interest Disclosure Form
The Conflict of Interest Policy is found in Part Three of the Rotary District 6270 Manual of Policies and Procedures (MoPP). A full copy of the MoPP is available here. The Conflict of Interest Policy is available here.

By submitting this form, you attest that you have read and understand the District Conflict of Interest Policy for covered individuals, and agree to conduct yourself in compliance with the policy, as well as to manage your duties and responsibilities in order to avoid any conflicts or potential conflicts of interest that may relate to your position as Board Member, District Committee Chair, District Rotary Foundation Committee Member, District Grant and Global Grant sub-committee member or Staff member of the District. In addition, you attest that the information provided below is, to the best of your knowledge, true, accurate, and complete.
Name*

First NameLast Name
1. Are you aware of any relationships between the District and yourself, or a member of your family, as defined by the letter or spirit of the Conflict of Interest policy, that may represent a conflict of interest?*

YesNo
Please list such relationships and the details of annual or potential financial benefits, as best you can estimate them.
2. During the past twelve (12) months, have you or a member of your family received any gifts or loans from any source from which the District buys goods or services, or otherwise has significant business dealings.*

YesNo
If “yes,” please list them, their source and their value, as best you can estimate it.
Exceptions: (If there are none, please indicate that fact.)*
Last Name
Signature*

Clear
Date Signed

MonthDayYear
Date
Date

MonthDayYear
Date
Form Signed?

YesNo
Should be Empty:

2024/25 Conflict of Interest Disclosure Form