Section 4 – Any Real, Potential, or Perceived Conflicts of Interest
Are you aware of any facts or circumstances in which you or a family member might be regarded as having a real, potential, or perceived Conflict of Interest?
* ◯ No * ◯ Yes
Please provide the name of who may have a real, potential, or perceived Conflict of Interest.
Select to identify the person you are providing information. If you have more than one family member, you can add additional family members at the end of this question by selecting Additional Disclosure.
* Select to self-identify * Select to identify an immediate family member
Please briefly describe the real, potential, or perceived Conflict of Interest.
Please briefly describe your family member’ s real, potential, or perceived Conflict of Interest. If you do not have any additional family members to add, and you have completed this question, please continue to the next section.
4879-7702-4986, v. 1 44