CONFLICT OF INTEREST DISCLOSURE STATEMENT
The University Senate Policy C1 requires disclosure in circumstances where a contract for goods or services may be awarded to a
person or firm in which a University employee has a material interest. Policy wording in Section 6.2 Business Decisions is as
follows: A conflict of interest appears to exist when faculty and staff members take part in decisions to transact the university’s
business with a company in which they have a material interest. Therefore, the responsibility rests with individuals to disclose
whenever they have influence over a decision about a proposed contract between the university and a company in which they have
substantial holdings and to withdraw from the university’s decision-making process.
Name of Person Submitting Statement: _______________________________________________
Title and Department at University: _________________________________________________
AFFIRMATION of University Employee:
I affirm the truth and completeness of the statements made above, and that I am “the above named University employee.”
Your typed name below indicates your approval of the form and confirms that all information is accurate.
Signed: ___________________________________ Date: ___________________
E-Mail Address: ____________________________ Ext: ____________________
SUPERVISOR’S ACKNOWLEDGEMENT: Name: ______________________________________
Signature: _________________________________ Date: ___________________
Acknowledgement by the Employee’s Supervisor indicates that they are aware of the apparent or real conflict of interest and
that they intend to manage the situation so that the employee does not have an opportunity to influence the University’s
business or financial decisions in ways that could lead to personal gain or give improper advantage to a member of the
employee’s immediate family; and the employee can objectively fulfill his or her obligations to the University.
NOTE: This form must be submitted to Purchasing for review PRIOR to final action being taken on the
purchase or contract. You will be contacted in writing with final decision of whether contract can be awarded.
SEND TO: email@example.com
Description of Goods, Services or Contract to be delivered and date(s) of contract:
Description of Financial Interest (i.e. describe in what manner you or your family member will derive a
financial gain or value from fulfilling this contract or purchase):
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