WOODS HOLE OCEANOGRAPHIC INSTITUTION

CONFLICT OF INTEREST DISCLOSURE STATEMENT

 

(Return to the Clerk of Woods Hole Oceanographic Institution (“WHOI”))

 

 

            Pursuant to the Conflict of Interest Policy for Trustees and Officers of WHOI (the “Policy”) requiring disclosure of certain interests, and consistent with the purposes and intentions of the Policy, I hereby state that, to my best knowledge, I or certain of my family members (as defined in the Policy) have the following affiliations or interests and have taken part in or are now taking part in the following transactions that, considered in conjunction with my position with or relation to WHOI, may constitute a conflict of interest (state “none” where applicable):

 

            1.         Financial or Business Relationships (Trustees and Officers): 

 

Identify any financial or business relationships (as defined in the Policy), of which you are aware, that you have with WHOI or any affiliated organization (as defined in the Policy) or with any organizations that do business with WHOI or any affiliated organization.  If none, so state:

 

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            2.         Financial or Business Relationships (Family Members): 

 

Identify any financial or business relationships, of which you are aware, that any family member has with WHOI or any affiliated organization or with any organizations that do business with WHOI or any affiliated organization.  If none, so state:

 

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            3.         Gifts, Gratuities and Entertainment:

 

Identify any instance, of which you are aware, in which you or any family member has accepted during the past twelve months any gift, loans, or entertainment valued at $100.00 or more from any source from which WHOI buys goods or services or otherwise has significant business dealings.  If none, so state:

 

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4.                   Government Affiliations. 

 

Please list below any elected or appointive office or position, of which you are aware, that you or any family member hold in any branch of government or in any regulatory agency having authority or jurisdiction over WHOI.  If none, so state:

 

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            5.         Involvement with Other Organizations:

 

List any other not-for-profit or for-profit organizations for which you serve as a trustee, director or officer.  If none, so state:

 

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            6.         Other:

 

List any other personal, familial, financial or business relationships that otherwise could be construed as affecting your independent, unbiased judgment in light of your decision-making authority or responsibilities for WHOI.  If none, so state:

 

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I hereby certify that the information disclosed herein is, to the best of my knowledge, complete and accurate.  I hereby agree to report promptly to the Clerk of WHOI or his or her designee any situation or transaction that may arise during the forthcoming year that constitutes an actual or potential conflict of interest and report the same on an amended Disclosure Statement.

 

 

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(Signature)

 

 

                                                            ________________________________

(Name)

 

 

                                                            ________________________________

(Title)

                                                                       

 

Date:    ___________________