Conflict of Interest Form

Covered Individuals

Kentucky Wesleyan's Individual Conflict of Interest Policy (available on the PantherNet) applies to covered individuals (College employees, volunteers, and Board of Trustee members) whose relationships with entities other than Kentucky Wesleyan may relate to their Wesleyan employment or association.

Conflict of interest

Conflicts of interest are situations in which covered individuals may have the opportunity to influence the College's business decisions in ways that would lead to personal gain or give improper advantage to members of the covered individual's immediate family (the spouse, domestic partner, parents, parent-in-law, sibling, children, or other relatives living at the same address as the covered individual) or the covered individual's associates.

Relevant external organizations

Conflicts of interest involve relevant external organizations, which are organizations outside of the College that the College is engaged in or intends to engage in business transactions or a sponsored project and are either a) related to the covered individual's responsibilities at Kentucky Wesleyan or b) funding a sponsored project or providing goods, services, and/or travel reimbursements under a sponsored project on which the covered individual is participating in any capacity.

Your name*

Your relationship with Kentucky Wesleyan*

employee
volunteer
member of the Board of Trustees

1a. Are you an officer, director, partner, trustee, employee, advisory board member, or agent of a relevant external organization?*

Yes
No

1b. Is anyone in your immediate family an officer, director, partner, trustee, employee, advisory board member, or agent of a relevant external organization?*

Yes
No

2a. Are you the owner of 5%, $5,000 worth, or a controlling interest of the voting stock of a relevant external organization?*

Yes
No

2b. Is anyone in your immediate family the owner of 5%, $5,000 worth, or a controlling interest of the voting stock of a relevant external organization?*

Yes
No

3a. Do you expect to receive more than $5,000 during the next twelve months from a relevant external organization or have your received such during the past twelve months?*

Yes
No

3b. Do anyone in your immediate family expect to receive more than $5,000 during the next twelve months from a relevant external organization or have your received such during the past twelve months?*

Yes
No

3c. Do you and the members of your immediate family expect to receive more than $5,000 during the next twelve months from a relevant external organization or have your received such during the past twelve months?*

Yes
No

4. If you answered "Yes" to any of the above questions, briefly describe the potential conflict. More information may be requested if needed.

Acknowledge and Agree*

By checking this box, I acknowledge that I have read and responded to the above items to the best of my knowledge. I agree that I must report any potential conflict of interest arising in the future by completing a new Disclosure Statement.

Signature*

By checking this box, I am confirming my intention to electronically sign this conflict of interest disclosure form.

Optional: Email

If you would like a copy of this form emailed to you, please include your email address below.