Conflict of Interest Questionnaire - Ronald McDonald House Charities West Michigan

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

company other provide

Email *

Name of company by which you are employed *

Your Position *

List all for-profit (taxable) organizations with which you or an immediate family member are affiliated as an officer, director, trustee, investor, majority owner, principal beneficiary, or potential investor. Include: Name of taxable (for-profit) organization and position held/by whom. *

To 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 above? (Check the boxes for those that are "yes") *

Sale, exchange or lease of property
Lending of money or other extension of credit
Furnishing of goods, services or facilities
Payment of compensation or expense reimbursement over $1,000
Transfer of any part of its income or assets
None

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 charities, nonprofits, or other tax-exempt organizations with which you or an immediate family member are currently an officer, director, trustee, principal beneficiary, or potential beneficiary. Please include your title/role. *

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?) *

Yes
No

If “yes”, please describe in detail the matter involved, including any mitigating circumstances.

Please disclose any additional relationships, activities, or circumstances that could present (or appear to present) a conflict of interest with your service to RMHCWM.

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 agree