Conflict of Interest Compliance Certificate

Executive Board, Volunteers and Staff

First Name *

Middle Initial

Last Name *

In order for us to properly review and archive your response, please carefully review all options when selecting entries in the next section.

For which NAPNAP group are you volunteering and completing this form? If you hold roles in multiple NAPNAP groups (e.g. SIG chair and chapter officer), please complete a separate COI online form for each. *

Select your chapter. *

Select your SIG. *

Select your position title within the aforementioned NAPNAP group. *

Appointed term start date. * +

Appointed term end date. For nationally appointed volunteers without a specific end date, please enter 12/31/2030. * +

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).

Read the full Conflict of Interest Avoidance and Disclosure Loyalty and Confidentiality/Nondisclosure policy.

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.

*

I Agree not to disclose confidential or proprietary information belonging to NAPNAP such as, but not limited to, NAPNAP finances, legal matters, businesses, programs or plans, publications, employee matters, relations with other organizations, membership lists, or sponsor lists.

I further agree upon request to execute such specific assignments or instruments and take any action necessary to enable NAPNAP to secure its copyright.

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). *

Yes

No

If you selected yes to the above question, please list the names of the organization(s) and any additional details.

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). *

Yes

No

If you selected yes to the above question, please list the names of the organization(s) and any additional details.

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). *

Yes

No

If you selected yes to the above question, please share details.

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? *

Yes

No

If you selected yes to the above question, please share details.

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? *

Yes

No

If you selected yes to the above question, please share details.

Declaration

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. *

I confirm

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. *

I agree

Your Full Name *

Today's Date * +