Conflict of interest disclosure form

10/16/2017
Steve Grenzow
Forms

NOTE: Only those who are serving in diocesan offices/ roles need to fill this form out. (for example, clergy, employees, or members of diocesan committees, etc.)

Please review The Episcopal Church of North Texas’ Conflict of Interest Policy and then sign the disclosure form below. If you prefer, you can print and sign a paper copy of the form: Conflict of Interest Disclosure Form – PDF

The Episcopal Church of North Texas Conflict of Interest Disclosure Form

First Name *

Last Name *

Position

Employee

Volunteer

Trustee

Acknowledgement *

I have reviewed the Conflict of Interest Policy of the Episcopal Diocese of Fort Worth.

Conflict Disclosure *

I have no conflict of interest to report

I have the following conflict(s) of interest to report

Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest between the Episcopal Diocese of Fort Worth and your personal interests, financial or otherwise.

List:

Please specify other nonprofit and for-profit boards you (and your spouse) sit on, any for-profit businesses for which you or an immediate family member are an officer or director, or a majority shareholder, and the name of your employer and any businesses you or a family member own

Paragraph Text

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed, and agree to abide by the Conflict of Interest Policy of the Episcopal Diocese of Fort Worth.

Signature *

Clear

Date *

Conflict of interest disclosure form

The Episcopal Church of North Texas Conflict of Interest Disclosure Form

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