CONFIDENTIAL
Financial Conflict of Interest Disclosure Form
To
be used if "yes" was selected on the Significant Financial Interest Form
Sponsor (funding agency):
Report all financial interest/relationships currently held, or held within the past 12 months (or during the
previous calendar year for annual disclosures), unless otherwise stated, indicating the amount of the financial
interest/relationship and the entity or organization. This form must be updated within 30 days of acquiring any
new or additional financial interests/relationships.
Pleas
e check and describe all applicable items that relate to the SFIs for you, your spouse, domestic partner, or
dependents:
1. Have you, your spouse, domestic partner, or dependents:
a) received remuneration from a publically traded entity whose value, when aggregated, is in excess of
$5,000.?
☐ Yes ☐ No
If yes, please describe each instance of salary or payment for services and dollar amounts:
b) D
o you have equity interests (e.g. stock, stock options, or other ownership interests) whose value, when
aggregated, is in excess of $5,000?
☐ Yes ☐ No
If yes, please describe each equity interest, including value of stock or ownership interest:
c) Ha
ve you received payment for Intellectual Property Rights (e.g. patents, copyrights, and royalties from
such rights) by an entity other than UWG?
☐ Yes ☐ No
If yes, please describe each instance of intellectual property rights, including amount paid:
d) S
ponsored or reimbursed travel (e.g. travel paid on your behalf)
☐ Yes ☐ No
If yes, please describe each instance of sponsored or reimbursed travel and dollar amount:
