CERTIFICATE OF DISCLOSURE STATEMENT AND REVIEW OF THE ION CENTER FOR VIOLENCE PREVENTION CONFLICT OF INTEREST POLICY In compliance with the policy regarding potential conflicts of interest as adopted by the Board of Trustees of the Ion Center For Violence Prevention: 1. I hereby submit that none of (i) myself; (ii) any immediate family member; (iii) any entity which employs me or any member of my immediate family has a compensation agreement; or (iv) any entity in which I own a 5% or greater interest, participate in any arrangement described in (a) through (d) below, other than as fully described in the spaces provided.a) Any transaction agreement or arrangement with The Ion Center For Violence Prevention, pursuant to which The Ion Center For Violence Prevention purchases goods and services:box ab) Any proposed or anticipated transaction, agreement, or arrangement with The Ion Center For Violence Prevention pursuant to which The Ion Center For Violence Prevention participants proposes to purchase goods or services:box bc) Any other transaction, agreement, or arrangement pursuant to which The Ion Center For Violence Prevention pays compensation:box cd) Any other proposed or anticipated transaction, agreement, or arrangement pursuant to which it is proposed that The Ion Center For Violence Prevention pay any compensation:box d2. Other than described below, neither I nor any member of my immediate family has accepted gifts of more than a nominal value, excessive entertainment or other favors in or from The Ion Center For Violence Prevention or any business or organization which in the past has had, currently has, or expects in the future to have any contract or business transaction with The Ion Center For Violence Prevention.box 23. By signing below, I hereby affirm that I have: a. received a copy of the conflict of interest policy; b. read and understand the conflict of interest policy; c. agreed to comply with the conflict of interest policy and have retained a copy of the policy for future reference; d. understand that The Ion Center For Violence Prevention is a charitable organization and in order to maintain its federal tax exemption, it must engage primarily in activities which accomplish one or more of its tax-exempt purposes; and e. disclosed all matters required to be disclosed pursuant to the conflict of interest policy.By typing your name below, you are signing this application electronically. You agree that your electronic signature is the equivalent of your manual signature on this form.(Required) I agree Name(Required) First Last Date(Required) Month Day Year Email(Required)
