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Get MD Biographical Information Form

Te rest of Part 2 and 3) I request exemption for: □ Financial Interest □ Employment Financial Interest Employment Name of Entity where the financial interest Employment to be Exempted: exists: Address of Entity: Your Position/Job Title: Interest to be Exempted: Current Value: □ Under $1,000 $5,000 □$5,000-$10,000 or More □$1,000- □$10,000 Explain below why you believe you may have financial interests or an employment situation that, in the absence of an exemption, will conflict.

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