Fillable Potential Conflict Disclosure (DeKalb County Government)

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Potential Conflict Disclosure (DeKalb County Government)

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SUPPLIER REGISTRATION PACKAGE
Potential Conflict Disclosure
Does any current or former DeKalb County Board of Commissioners, CEO, Officer, or Employee hold an
interest of 5% or more, or any other interest, in the business or in any of the business subcontractors?
(“Interest” as used herein also includes membership on the board of directors of “for-profit” corporations.)
Yes No Unsure
Please provide the following information (*Required):
*Name:
*
Position:
*Organization:
Busi
ness/Subcontractor:
Int
erest Owned:
Does
any member of the immediate family of any current or former DeKalb County Board of Commissioners,
CEO, Officer, or Employee hold an interest of 5% or more, or any other interest, in the business or in any of
the business subcontractors? (“Interest” as used herein also includes membership on the board of directors of
“for-profit” corporations.)
Yes No Unsure
If Yes or Unsure, please provide the following information:
Nam
e of Relative:
Relationship:
Name of DeKalb County Personnel or Employee:
Comments:
Approved Revision 05/09/2018
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DeKalb County also reserves the right not to do business with anyone related by blood or marriage to anyone
in the categories of persons listed above when the relationship has the appearance of a “conflict-of-interest”. Is
the business aware of any relationships, not identified above, that may create the appearance of a “conflict- of-
interest”?
Yes No Unsure
If Yes or Unsure, please describe (use a separate sheet if necessary):
Are you a DeKalb County Former Employee or are any officers within your organization a former
employee? (To participate in doing business with DeKalb County, you have to be a former employee equal to
or greater than two years)
Yes No
If
Yes, please provide name of employee:
La
st Date of employment with DeKalb County Government:
Approved Revision 05/09/2018
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Potential Conflict Disclosure (DeKalb County Government)

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Completed 5 August 2020

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