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First Name: |
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Last Name: |
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Daytime Phone: |
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E-Mail: |
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Your Position: |
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Institution: |
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1. Your employer: |
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Employer address: |
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2. Spouse's name: |
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Spouse's employer: |
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Employer address: |
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City: |
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3. List dependent children |
Child 1: |
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Child 2: |
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Child 3: |
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Child 4: |
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Child 5: |
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Additional dependent children: |
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Click on one of the following for definition of "Business Entity" and "Substantial Interest" |
4. List all Business entities in which you personally own an interest of 10% or more |
Business 1: |
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Business 2: |
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Business 3: |
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Business 4: |
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Business 5: |
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Wholly owned Subsidiary 1: |
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Wholly owned Subsidiary 2: |
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Wholly owned Subsidiary 3: |
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Wholly owned Subsidiary 4: |
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Wholly owned Subsidiary 5: |
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Additional business or wholly owned subsidiaries : |
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5. List all business entities in which your spouse owns an interest of 10% or more |
Business 1: |
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Business 2: |
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Business 3: |
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Business 4: |
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Business 5: |
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Additional spouse owned businesses: |
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6. List all of the business entities not included in #4 or #5 above in which you, your spouse and your dependant children, collectively, own an interest of 10% or more |
Business 1: |
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Business 2: |
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Business 3: |
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Business 4: |
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Additional collectively owned businesses: |
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7. List all other businesses entities, other than publicly traded corporations, from which you, your spouse and your dependant children, collectively, earn, or will earn, more than $10,000 per annum in unearned income. |
Business 1: |
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Business 2: |
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Business 3: |
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Business 4: |
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Business 5: |
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Additional businesses: |
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8. List all of the entities for which you, your spouse and your dependent children serves as a director, officer or trustee, other than uncompensated service on the Board of a 'not for profit' corporation. |
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Entity 2: |
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Entity 3: |
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Entity 4: |
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Entity 5: |
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Additional entities: |
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9. What business relationships do you , your employer, your spouse, your spouse's employer or entities in which you have a substantial interest, currently have with the University ? |
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10. What other business interests do you have, that are not disclosed above, that could cause a conflict of interest or the appearance of a conflict of interest, with the University ? |
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