Fillable Conflict of Interest Disclosure Details Form Question E (Vanderbilt University)

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Conflict of Interest Disclosure Details Form Question E (Vanderbilt University)

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Conflict of Interest Disclosure Details Form – Question E
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part E. Legal Proceedings and Debarment
1) Describe any legal proceedings and/or debarment in which you are or have been involved in the past year:
2) Have you ever, under your name or another name, been convicted of or pled guilty or no contest to a Felony or Misdemeanor
crime?
( ) No ( ) Yes
2a. If you checked “Yes” above, describe the nature and circumstances of the arrest or conviction, including date and jurisdiction.
3) Do you currently have charges pending?
( ) No ( ) Yes
3a. If you checked “Yes” above, describe the nature and circumstances of the arrest or conviction, including date and jurisdiction.
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Conflict of Interest Disclosure Details Form Question E (Vanderbilt University)

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Completed 24 July 2020

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