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I hereby certify that I have, or may have, a financial interest or conflicting interest as noted below. The potential conflict is with the following individual and/or organization with which the Linn-Mar CSD has, or might reasonably have in the future, a relationship with; or which Linn-Mar CSD may enter into a transaction with or compete with.
Name of conflicting or financial interest (individual or company, etc.): _________________________________
Reason for potential conflict (e.g. family relationship, financial relationship, etc.): ________________________
All facts pertinent to the conflicting or financial interest: ____________________________________________
_____ I have no conflict of interest to disclose.
_____ I hereby certify that I have read and understand Policy 403.17 Employee Conflict of Interest, which I received a copy of, and that the above information is true, correct, and complete to the best of my knowledge, information, and belief. I further certify that I will comply with the requirements of Policy 403.17 Employee Conflict of Interest.
Employee's Signature: _______________________________________ Date: _______________________
Printed Name: ______________________________________________ Fiscal Year: __________________
Superintendent's Signature: ___________________________________ Date: ________________________
Complete additional forms for multiple conflicts/financial interests, as needed.
Please return this form to:
Human Resources Office
3556 Winslow Road, Marion IA 52302
Adopted: 1/22
Revised: 4/23; 9/24
Related Policy (Code#): 403.17