Fill - Free fillable Declaration-of-business-interest - Declaration of Business Interest PDF form

DECLARATION OF BUSINESS INTEREST

In compliance with Southern Utah University policy and Utah Code section 67-16, I disclose and

submit the following information concerning my business interest:

Business Name: ___________________________________________________________________

Type of Business: (Please check one)

Corporation (Public) _____

Corporation (Small business) _____

Partnership _____

Sole Proprietorship _____

Other (Describe) _____

Nature of Interest:

Personal ownership

Yes No Percentage ____________________

Related to owner Yes No Relationship ____________________

Employment Yes No Position ____________________

Other Yes No Description ____________________

Business Product or Service:

__________________________________________________________________________________

Nature of Proposed Business Transaction with Southern Utah University:

__________________________________________________________________________________

I certify that the above is an accurate disclosure of my business interests as defined. I

understand that such disclosure must be made on a per transaction basis to the supervising dean

or vice president and the person representing the University in the transaction.

___________________________________ __________________________

(Employee's Department) (Employee's Name)

___________________________________ __________________________

(Employee's Signature) (Date)

___________________________________ __________________________

(Dean/Vice President) (Date)

___________________________________ __________________________

(Director of Purchasing) (Date)

Completed forms should be sent to the Purchasing Office for final approval. Original copies will be kept in the

Purchasing Office and a copy will be forwarded to the Attorney General’s Office.

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