2025 Conflict of Interest Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone *Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeName of company by which you are employed * (other other that Your Position *Email *List all taxable organizations (other than as stated in #2 above) with which you are currently affiliated as an officer, director, trustee, investor, majority owner, principal beneficiary, potential owner or investor. * Visual Text Include: Name of Taxable Organization and Position Held/By WhomTo your knowledge, has the Ronald McDonald House Charities West Michigan engaged in any of the following activities with you, a member of your immediate family or any of the entities listed in questions 2 and 5 above? (Check the boxes for those that are "yes") *Sale, exchange or lease of propertyLending of money or other extension of creditFurnishing of goods, services or facilitiesPayment of compensation or expense reimbursement over $1,000Transfer of any part of its income or assetsNoneA checkmark indicates ‘yes’, leaving it blank indicates the response is ‘no’. If the answer to any questions in number 6 above is “yes”, please provide a detailed statement of your knowledge of the transactions. If you are not aware of the details of a transaction, please provide the name and phone number of a person at the entity who can provide this information. *List all other charities or other not-for-profit organizations with which you (or a member of your immediate family) are currently an officer, director, trustee, principal beneficiary or potential beneficiary. *Visual Text 8. During the past ten years, have you been convicted in a criminal proceeding, or are you a named subject of a pending criminal proceeding (excluding traffic violations and other minor offenses?) *YesNoIf “yes”, please describe in detail the matter involved, including any mitigating circumstances.I certify that I have read and understand the attached Conflicts of Interest and Documentation Policy. I further certify that to the best of my knowledge and belief the information I have provided in this Questionnaire is complete and accurate. I will promptly notify the CEO if any of the information I provided herein changes during the remainder of my term of service with the Ronald McDonald House Charities West Michigan. *I agreeSubmit