Conflict of Interest Policy: Acceptance and Disclosure Form

I have read the statement of policy regarding conflicts of interest.I understand that the purposes of this policy are:

a. to protect the integrity of the Library’s decision-making process,

b. to enable our constituencies to have confidence in our integrity, and

c. to protect the integrity and reputation of volunteers, staff, and Board members.

Trustees:Upon or before signing the Oath of Office, I will make a full, written disclosure of interests, relationships, and holdings that could potentially result in a conflict of interest.I understand that this written disclosure will be kept on file, and I will update it whenever appropriate.

In the course of meetings or activities, I will disclose any interests in a transaction or decision where I (including my business or other nonprofit affiliation), my family and/or my significant other, employer, or close associates will receive a benefit or gain.After disclosure, I understand that I will be asked to leave the room for the discussion and will not be permitted to vote on the question.

I understand that this policy is meant to be a supplement to good judgment, and I will respect its spirit as well as its wording.

Please initial one of the two statements below that best describes your compliance with this Conflict of Interest policy at this time.Please sign and date the form and submit it to the Board President.

______ I do hereby declare that I have no such perceived conflicts of interest at this time.

______ I do have one or more possible conflicts of interest, and I have listed and explained them on a separate page.I will submit that document to the Board President along with this signed page.

Signed:____________________________________________ Date:______________________

_____Disclosures on File

Approved by _________________________________________ Date: _____________________

Approved: 10/11/12

Revised: 12/10/15