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Get Executive Order 2008 454 Form

DISCLOSURE OF CONFLICT OF INTEREST STATEMENT CHAIRPERSON TO FROM Name Position Agency Board or Commission Telephone MEMBER OF BOARD OR COMMISSION COMPLETES Executive Order 2008-454 requires members appointed to policy making and regulatory boards or commissions to disclose in writing any interest he or she possesses or acquires that might reasonably tend to create a conflict with the public interest. Please be advised that I have the following business financial or personal interest which may create an actual or perceived conflict The following matter is before this board or commission and is related to the above interest I have the following duties or responsibilities to the board or commission that are related to the above interest a* A decision on this matter will take place or took place on mm/dd/yyyy Yes b. I participated or plan to participate in the decision making process on this matter. I did/will not participate in the decision making process on this matter. I request advice from the board or commission regarding this matter. Date Signature BOARD OR COMMISSION DETERMINATION 1. The facts disclosed do not indicate a conflict of interest exists. 3. The board or commission action s Chair No. Please be advised that I have the following business financial or personal interest which may create an actual or perceived conflict The following matter is before this board or commission and is related to the above interest I have the following duties or responsibilities to the board or commission that are related to the above interest a* A decision on this matter will take place or took place on mm/dd/yyyy Yes b. I participated or plan to participate in the decision making process on this matter. I did/will not participate in the decision making process on this matter. I participated or plan to participate in the decision making process on this matter. I did/will not participate in the decision making process on this matter. I request advice from the board or commission regarding this matter. Date Signature BOARD OR COMMISSION DETERMINATION 1. I request advice from the board or commission regarding this matter. Date Signature BOARD OR COMMISSION DETERMINATION 1. The facts disclosed do not indicate a conflict of interest exists. 3. The board or commission action s Chair No. Please be advised that I have the following business financial or personal interest which may create an actual or perceived conflict The following matter is before this board or commission and is related to the above interest I have the following duties or responsibilities to the board or commission that are related to the above interest a* A decision on this matter will take place or took place on mm/dd/yyyy Yes b. I participated or plan to participate in the decision making process on this matter. I did/will not participate in the decision making process on this matter. I request advice from the board or commission regarding this matter. Date Signature BOARD OR COMMISSION DETERMINATION 1.

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