Personal Information
- Name: [Your Full Name]
- Position/Title: [Your Position/Title at Endaoment]
- Department/Unit: [Your Department or Unit]
- Date: [Date of Submission]
Disclosure Statement
1. Personal and Family Business Relationships
- Description: Detail any personal, family, or business relationships that you or your family members have with Endaoment. Include the nature and extent of these relationships.
2. Ownership Interests
- Entities: List any entities in which you or your family members hold ownership interests that might present a conflict of interest with Endaoment.
3. Positions of Influence
- Roles: Identify any positions of influence you or your family members hold in other organizations that do business with or compete with Endaoment.
4. Charitable Engagements
- Organizations: Disclose any fiduciary roles or significant contributions you or your family members make to charitable organizations that may receive support from or provide support to Endaoment.
5. Other Relevant Relationships
- Details: Provide information about any other relationships or situations that might constitute a conflict of interest or be perceived as such.
Financial Interests
- Details: Describe any financial interests or benefits that you or your family might have that are related to Endaoment’s activities.
Involvement in Decision-Making
- Details: Explain your role in decision-making processes at Endaoment related to any of the disclosed conflicts.
Action Taken
- Mitigation Measures: Describe any measures you have taken or will take to mitigate any potential conflicts of interest.
Declaration
I declare that the information provided is true and complete to the best of my knowledge and I commit to update this disclosure promptly should any relevant changes in my circumstances occur. I understand that failure to disclose or properly manage a conflict of interest may result in disciplinary action up to and including termination.- Signature: [Your Signature]
- Date: [Date of Signing]
For Office Use Only
- Received By: [Name of the Ethics Officer/HR Representative]
- Date Received: [Date of Receipt]
-
Review and Comments:
- [Comments or actions taken by the reviewing officer]
Please return the completed form to the Endaoment Ethics Office at ethics@endaoment.org.