Note: You will be able to print this form after your initial submission.

Date:
First Name:			Last Name:			Suffix:
Daytime Phone:
E-Mail:
Your Position:	Board of Governors Board of Trustees UNC President Chancellor CFO		Institution:	UNC System Appalachian State University East Carolina University Elizabeth City State University Fayetteville State University North Carolina A&T State University North Carolina Central University North Carolina School of the Arts North Carolina School of Science and Mathematics North Carolina State University The University of North Carolina at Asheville The University of North Carolina at Chapel Hill The University of North Carolina at Charlotte The University of North Carolina at Greensboro The University of North Carolina at Pembroke The University of North Carolina at Wilmington Western Carolina University Winston-Salem State University
1. Your employer:
Employer address:
City:			State:	None NC AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY		Zip:
2. Spouse's name:
Spouse's employer:
Employer address:
City:			State:	None AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY		Zip:
3. List dependent children
Child 1:
Child 2:
Child 3:
Child 4:
Child 5:
Additional dependent children:	N/A
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:
Business 2:
Business 3:
Business 4:
Business 5:
Wholly owned Subsidiary 1:
Wholly owned Subsidiary 2:
Wholly owned Subsidiary 3:
Wholly owned Subsidiary 4:
Wholly owned Subsidiary 5:
Additional business or wholly owned subsidiaries :	N/A
5. List all business entities in which your spouse owns an interest of 10% or more
Business 1:
Business 2:
Business 3:
Business 4:
Business 5:
Additional spouse owned businesses:	N/A
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:
Business 2:
Business 3:
Business 4:
Business 5:
Additional collectively owned businesses:	N/A
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:
Business 2:
Business 3:
Business 4:
Business 5:
Additional businesses:	N/A
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.
Entity 1:
Entity 2:
Entity 3:
Entity 4:
Entity 5:
Additional entities:	N/A
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 ?
	N/A
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 ?
	N/A