UOA Financial Disclosure and Conflict of Interest Statement

Financial Disclosure and Conflict of Interest Statement
United Opticians Assocation Financial Disclousure and Conflict of Interest Statement

Purpose: Pursuant to policy adopted by the United Opticians Assocation ("UOA") Executive/Finance Committee, every Board Member, Cheif Executive Officer, employee and contractor of UOA is required to complete and sign a Financial Disclosure and Conflict of Interest Statement annually or an Amended Statement any time a potential conflict of interest may arise.
Annual StatementAmended Statement
Director/Employee/Board Member Information
Name*

First NameLast Name
UOA OfficerUOA Board MemberUOA Chief Executive OfficerUOA EmployeeIndependent Contractor
Business Name (if other than UOA)
Business Phone Number (if other than UOA)

Area CodePhone Number
Business Address (if other than UOA)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number*

Area CodePhone Number
Occupation & Title:
a. CEO/Employee/Board Member
b. Spouse of CEO/Employee/Board Member
Financial Disclosure
Please disclose, for you or any immediate family member (defined as a spouse, parent, sibling, grandparent, grandchild or child), any financial interest in any company or firm that does business with UOA, or has stated a position that is contrary to UOA's mission, goals, or initiatives. For purposes of answering this question, “financial interest” does not include any agreement, arrangement or relationship which is based on terms offered to the general public:
Conflicts of Interest
Please disclose, for you or any immediate family member (defined as a spouse, parent, sibling, grandparent, grandchild or child), the following:
Any personal financial interests, direct or indirect, not listed in answer to the “Financial Disclosure” section above, that could conflict or appear to conflict with Your duties and responsibilities to UOA.
Any acceptance of employment or compensation from any UOA members, contractors, partners, supplier or vendors.
Any interest in property, tangible or intangible, or any other assets or business that may constitute or cause a conflict of interest with your duties on behalf of UOA.
Are there any financial or in-kind support or partnership agreements between your employer and UOA? If so, describe the agreements and terms and your involvement in securing the agreement.
Notice
Any employee who knowingly and willfully provides false, misleading or incomplete information on this form shall be subject to disciplinary action, up to and including termination. Any Board Member who knowingly and willfully provides false, misleading or incomplete information on this form shall be subject to disciplinary action, up to and including removal from the Board.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: