Conflict of Interest Compliance Certificate

Executive Board, Volunteers and Staff

In order for us to properly review and archive your response, please carefully review all options when selecting entries in the next section.
Select your position title within the aforementioned NAPNAP group. *

As outlined in the Conflict of Interest Policy, employees, officers, volunteers, representatives and members of the Executive Board ("members") must pay special attention to issues of potential bias in order to maintain the integrity of, and public confidence in, NAPNAP. To ensure that the association monitors issues of professional integrity, disclosure of actual or potential conflicts of interest is required of all members on an annual basis.  

Members should disclose interests that could: i) significantly impair their objectivity in carrying out duties and responsibilities for NAPNAP, or ii) create an unfair advantage for them or any person or organization that could result in their securing a direct and material gain through  any of NAPNAP’s products or services. For the purposes of this policy, any activities that could lead a reasonable person to question a member’s objectivity, or whether an unfair advantage has been created, constitutes a potential conflict of interest and should be disclosed in this form.

Members must also disclose any relevant interests of parties with whom they have current contractual relationships or substantial common interests that could be perceived as unduly influencing, or potentially unduly influencing, their judgment (for example, their employer, close professional associates, consultancies, publication agreements, or advisory or funding relationships).
Compliance Certification
I have received, carefully read and agree to the terms of the conflict of interest avoidance/disclosure, compensation/joint venture/loyalty, confidentiality/non-disclosure and copyright policies of NAPNAP (the Organization). In the event that I become aware of any situation that poses an actual, potential or the appearance of a conflict of interest between me and the Organization or between my family members and the Organization, I shall promptly disclose all pertinent facts and leadership positions held to the senior staff executive and president of the Organization as appropriate.


Relevant Affiliations and Financial or Other Interests

1. Do you receive financial support from any entity or other organization with an interest related to the work of NAPNAP? (Example: Grants, research support, honoraria, Speakers’ Bureau, speeches, training). *
2. Do you have investments in any business entity with an interest related to the work of NAPNAP? (Example: Major stock shareholder, ownerships, partnerships, joint ventures, board membership). *
3. Do you own any intellectual property rights that might be affected by the work of NAPNAP? (Example: Patents, trademarks or commercial copyrights, including pending applications). *
4. Are you engaged in any professional or other activities that outside parties could consider a conflict of interest or that could create the perception of a conflict of interest regarding your NAPNAP affiliation? *
5. If not already disclosed above, are you aware of any aspect of your work for NAPNAP that will enable you to use proprietary information to create for you a competitive advantage in your professional, financial or business dealings? *


Answering “Yes” to a question on this form does not necessarily mean that a conflict is present or that you will be unable to perform your designated function/role with NAPNAP. If in doubt about whether an interest should be disclosed, individuals are encouraged to disclose that information.

I hereby declare that the information in and accompanying this disclosure is true and complete to the best of my knowledge and belief. I declare that I have disclosed all associations required for disclosure under NAPNAP’s Conflict of Interest Policy; and that, except as declared, I do not consider that any of the associations present a conflict of interest.

Should there be any change to the above information and declaration, I will promptly notify the Board President or Senior Staff Executive and complete a Supplemental Compliance Certificate describing the changes.

By signing below, I acknowledge that I have received and carefully read and agree to NAPNAP’s policies listed above and will comply with all requirements.

By clicking "I confirm", you confirm that you have reviewed the Conflict of Interest Avoidance and Disclosure Loyalty and Confidentiality/Nondisclosure policy to complete this compliance certificate. *
By clicking “I agree”, you agree that your typed name represents your legal signature and you confirm that the information contained herein is complete and accurate to the best of your knowledge. *