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 .
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