NORTH DAKOTA STATE UNIVERSITY CONFLICT OF INTEREST DISCLOSURE STATEMENT
(Please read NDSU Policy 151, Conflict of Interest, before continuing.)

Name: _______________________________________________________

Title: ________________________________________________________

Department: __________________________________________________

Please check the appropriate box (or boxes) below:

1. I DO NOT have a financial interest in any contract(s) involving the expenditure of public or institutional funds entered into by North Dakota state University nor, to my knowledge, does anyone under my direct supervision. (If you check this box, skip to the bottom of the form, read the certification, and sign and date the form.)

2. I DO have a financial interest in a contract(s) involving the expenditure of public or institutional funds entered into by North Dakota State University. (If you checked this box, continue completing the rest of the form, read the certification, and sign and date at the bottom.)

3. I DO have a personal or financial interest in an agreement, transaction or relationship which could conflict or have the appearance of a conflict with my obligations to act in the best interest of NDSU. (If you checked this box, continue completing the rest of the form, read the certification, and sign and date at the bottom.)

Description of Financial Interest (Also fill out Attachment A):
____________________________________________________________
____________________________________________________________
____________________________________________________________

Description of Activity (please include identity of commercial entities involved):
____________________________________________________________
____________________________________________________________
____________________________________________________________

I hereby certify that I have read and understand the NDSU Policy on Conflicts of Interest. I further cerfity that, to the best of my knowledge, the contents of this Conflict of Interest Disclosure Statement are complete and accurate. If after signing this form my financial interest situation changes that would create a conflict of interest, I will notify the University immediately.

Employee Signature: _________________________ Date: __________

Printed Name: ______________________________

Supervisor's Signature: _______________________ Date: __________

After completing the form, please submit to the Purchasing Office, Old Main Room 17.

(March 2006)