Office of Research and Sponsored Programs
Federal Disclosure Form
Please forward the completed form to the Office of Research and Sponsored Programs.
For questions, please contact our office at (559) 278-0840.
Office Telephone Number:
Department: Mail Stop:
DHHS/NIH
NSF
Other Federal Agency
E-mail address:
Home Address:
Title of Project:
Amount Applied for: $
Name of Principal Contact Person at Agency:
For Period:
Agency to which you are applying or from which the grant was received:
Office Telephone Number: E-mail address:
Name of Applicant and Spouse:
(Last, first , middle)
Name of the Funding Agency:
Please note: If you are applying to a non-governmental agency, please fill out the CA Form 700 U. You can download the form from the ORSP
web site at http://csufresno.edu/grants/pdfdocuments/conflictofinterest.pdf
First Disclosure Relating to this Proposal
Change, Renewal, or Extension of Grant or Contract
Change of Financial Interest Status
Final Disclosure Related to this Proposal
Significant (reportable) Financial Interests:
I have no reportable financial interests.
I have reportable financial interests declared on the attached
Please attach on numbered page(s) for each financial interest as follows:
1) Name and Address of Interest
2) Owners of Interest
3) Amount of your combined (applicant and spouse) investment in them
4) The nature and titles used your participation in them (salary, royalties, etc.)
5) Your intellectual property rights (patents, copyrights) being used by them
6) Any agreement for deferred remuneration, compensation, of financial gain of any kind
I have read all related campus, state and federal policies and regulations pertaining to Conflict of Interest.
I declare under penalty of perjury under the laws of the State of California that I have used all reasonable diligence in preparing
this Disclosure and that, to the best of my knowledge and belief , it is true and complete.
Signature:
_______ pages.
Date:
