New Vendor Conflict of Interest Disclosure - Northwood University Forms

Definitions

Employee – any individual who is presently employed by the University.
Former employee – an individual who has retired or separated from the University, was dismissed, or was otherwise formerly employed by the University.
Near Relative – the spouse, domestic partner, child, parent, brother, sister, son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, or sister-in-law of a University employee, and step-relatives in the same relationship.

Disclosure Fields

Are you or any principal member of the organization currently an employee of any entity of Northwood University (including but not limited to any campus or extension center)? *

Yes
No

Are you or any principal member of the organization a former employee, within the last two years, of any campus or extension center of Northwood University? *

Yes
No

Are you or any principal member of the organization a near relative of an employee of any campus or extension center of Northwood University? *

Yes
No

Part B

Since you answered “yes” to one or more of the above questions, you must complete this additional information for each individual identified as part of the above answer.

Please list current and/or former positions held by you or your near relative:	Please describe your financial interest (or that of your near relative) in the transaction:	Please describe your financial interest (or that of your near relative) in any business entity involved the transaction:	Do you (or your near relative) have any past, current, or future responsibility for, involvement in, or direct influence on any of the negotiations, transactions, planning, arrangements, or any part of the decision-making process relevant to the contract?	Please explain this involvement:	Do you certify that no University time, material, equipment, or facilities have been or will be used in connection with any resulting purchase order or contract?	Actions

There are no Entries.

Verification *

I certify that the above information is true

Full Legal Name of Authorized Representative *

Title of Authorized Representative *

Business Name *

Date *

Phone

This field is for validation purposes and should be left unchanged.

Name	Location	Department	Position	Date of Separation