Guilford County Continuum of Care

Conflict of Interest Disclosure Policy

ACKNOWLEDGMENT AND DISCLOSURE STATEMENT

The undersigned person, who has been appointed or elected to serve the Guilford County Continuum of Care in the capacity reflected below, hereby confirms that the undersigned has read and does understand the Guilford County Continuum of Care’s Conflict of Interest Policy as outlined in the Guilford County Continuum of Care Governance Charter and has received a copy of that Charter for present and future reference.

The undersigned agrees to take appropriate action with respect thereto, including initiative in disclosing activities, interests, or relationships wherever an actual or potential conflict of interest may exist, and to otherwise comply in all respects with the Conflicts of Interest Policy.

Consistent with the foregoing, the undersigned makes the following disclosure of any and all Interests as defined in the Conflicts of Interest Policy, in accordance with applicable reporting responsibilities (if none, please write “NONE”)

Disclosed Interests

First Name

Last Name

Position

Email

Date

Signature

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Continuum of Care Conflict of Interest Disclosure Policy