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PTS Conflict of Interest Form
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Conflict of Interest Policy
* Name of PTS community member:
*
Relationship to PTS: (check all that apply)
Employee - (non-faculty or non-officer)
Faculty
Officer of the Corporation
A Member of the Board of Directors
Contractor, vendor, consultant
Volunteer
For purposes herein, “affiliated persons” include the following:
Any immediate family member (including a spouse of an immediate family member);
Any employer;
Any corporation, partnership, or organization of which you are an officer or a partner or are, directly or indirectly (i.e., through one or more immediate family members), the beneficial owner of 35 percent or more of the voting power or profits interest; or
Any trust or other estate in which you, directly or indirectly (i.e., through one or more immediate family members), have a substantial beneficial interest or to which you serve as a trustee or in a similar capacity.
* Did you or any of your affiliated persons have a business relationship, financial interest or other interest with PTS in the past year?
Yes
No
If yes, please describe the nature of the business relationship:
* Were you or any of your affiliated persons indebted to pay money to PTS or was PTS indebted to pay money to you or any of your affiliated persons at any time in the past year?
Yes
No
If yes, please describe the indebtedness:
* In the past year, did you or any of your affiliated persons receive financial aid or other assistance from PTS?
Yes
No
If yes, please describe the benefit:
I HEREBY CONFIRM
that (1) I have received a copy of the Conflict of Interest Code; (2) I have read and understand the Conflict of Interest Code; (3) I agree to comply with the Conflict of Interest Code, including the disclosure of any conflict or potential conflict of interest; (4) I have conducted reasonable investigation to ensure that the information contained in this disclosure statement is complete and correct; and (5) I understand the Seminary is a charitable organization and, in order to maintain its federal tax exemption, must engage primarily in activities that accomplish one or more of its tax-exempt purposes.
* Sign (type your full name)
* Date:
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