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Conflict of Interest Form

Conflict of Interest Form

PUMP Board of Directors – Please complete the following steps:

Read the PUMP Conflict of Interest Policy.
Complete the Annual Disclosure Statement below.

The Executive Committee will review all submissions and reach out to you with any questions.

Thank you!

1. Name*
First Last
2. Position (check all that apply):*
- I am a voting Director.
- I am an Officer.
3. I affirm the following:*
- I have received a copy of the PUMP Conflict of Interest Policy.
- I have read and understand the policy.
- I agree to comply with the policy.
- I understand that PUMP is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of tax-exempt purposes.
4. Do you have a financial interest (current or potential), including a compensation arrangement, as defined in the Conflict of Interest policy with PUMP?*
- Yes
- No
4a. If yes, please describe it:
4b. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy?
5. In the past, have you had a financial interest, including a compensation arrangement, as defined in the Conflict of Interest policy with PUMP?*
- Yes
- No
5a. If yes, please describe it, including when (approximately):
5b. If yes, has the financial interest been disclosed, as provided in the Conflict of Interest policy?
6. Are you an independent director, as defined in the Conflict of Interest policy?*
- Yes
- No
6a. If you are not independent, why?
7. Have you been elected to Public Office or Position, or are you currently on the staff of a Member of Public Office?*
- Yes
- No
7a. If yes, please describe the Office and/or your position:
7b. If yes, has the Office and/or position interest been disclosed, as provided in the Conflict of Interest policy?
8. I pledge to donate what I feel is a meaningful amount to PUMP.*
- Yes
- No
9. Digital Signature*
By checking this box, I affirm that the information provided by me in this form is accurate to the best of my knowledge.
Date*
MM slash DD slash YYYY

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