CLC Potential Conflict of Interest Disclosure
For U.S. Dept. of Labor Grants
living at your same address) an officer, director, partner, trustee, employee, advisory
board member, or agent of any external organization from which goods or services
will be obtained under this project?
than five percent (5%) of the voting stock or controlling interest of any external
organization from which goods or services will be obtained under this project?
salary, compensation, consulting fees, honoraria, etc. from any organization other
than MnSCU for any activity related to your duties as a MnSCU employee?
disclosure or potential conflicts of interest that you would like to make known?
I have read and understand the Central Lakes College Code of Conduct Procedure pertaining to grant proposals;
have read MnSCU Procedures 1C.0.1 Employee Code of Conduct and 1C.2 Fraudulent or Other Dishonest Acts, and Minnesota Statutes 43A.38 & 43A.39, the U.S Department of Labor Administrative Requirements at 29 CFR Part 95, and other pertinent regulations; have made all required financial disclosures; will comply with any conditions or restrictions imposed by the institution to manage, reduce or eliminate actual or potential conflicts of interest should
I decide to proceed with the project; and will make Central Lakes College Administration aware in writing of any new conflicts of interest that arise during the period of the award, should the award be received.
Signature: ___________________________________________ Date: ____________________
KC:JC – 06/15/2017: CLC #22.214.171.124