Disclosure of Substantial Interests

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:   Institution:
 
1. Your employer:
Employer address:
 
City:   State:   Zip:
 
2. Spouse's name:
Spouse's employer:
Employer address:
 
City:   State:   Zip:
 
3. List dependent children
Child 1:
Child 2:
Child 3:
Child 4:
Child 5:
Additional
dependent
children:
 
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 :
 
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:
 
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:
 
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:
 
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:
 
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 ?
 
 
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 ?