CONFLICT OF INTEREST DISCLOSURE FORM Networked Digital Library of Theses and Dissertations The purpose of the conflict of interest policy is to protect the Networked Digital Library of Theses and Dissertations’ interest when it is contemplating entering into a transaction or arrangement that might benefit the private interest of an officer, director or committee member of NDLTD or might result in a possible excess benefit transaction. The scope of the policy includes actions of officers, directors or committee members that might be construed as involving a conflict of interest. As a current Board member, Officer of the NDLTD or Committee member please acknowledge: • • • •

that you have received a copy of the Conflict of Interest Policy; that you have read and understand the Policy; that you agree to comply with the Policy; and, that you understand the NDLTD is a charitable and educational organization (as per Section 501 (c)(3) of the USA Internal Revenue Code of 1986) and, in order to maintain its USA federal tax exemption it must engage in activities which accomplish one or more of its tax-exempt purposes.

Please describe below any transactions, relationships, positions you hold (volunteer or otherwise), or circumstances that you believe could contribute to a conflict of interest, as described in the NDLTD Conflict of Interest Policy. - - - - - - - - - - - - - - - - - - Please complete the following. - - - - - - - - - - - - - - - - - - I have no conflict of interest to report. ___ I have the following potential conflict(s) of interest to report.

I acknowledge that I have received, read and understood the Conflict of Interest Policy and that I agree to comply with it. I understand that the NDLTD is a charitable and educational organization and certify that the information set forth above is true and complete to the best of my knowledge. Signature: ___________________________________________ Printed Name: ________________________________________ Date: ____________________