CONFLICT OF INTEREST DISCLOSURE STATEMENT
TO REVIEW ACR CONFLICT OF INTEREST POLICY - http://www.acrwebsite.org/go/conflictinterest 

Note: In order to be more comprehensive, this statement of disclosure also requires you to provide information with respect to certain parties that are related to you. These persons are termed “affiliated persons” and include the following: a. your spouse, domestic partner, child, mother, father, brother or sister; b. any corporation or organization of which you are a board member, an officer, a partner, participate in management or an employee.
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1. Name of board member or ACR officer: *
[enter your name]
2. Have you or any of your affiliated persons provided paid services or property to ACR in the past year other than your duties as a board member or officer? *
If yes, please describe the nature of the services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:
3. In the past year, did you or any of your affiliated persons receive, or become entitled to receive, from an organization that transacts with ACR, any individual gifts or other personal benefits that exceed $250 in value or in the aggregate could be valued in excess of $1,000? *
If yes, please describe the benefit(s) and the estimated value of each benefit:
 Part 1: CASH OR CASH EQUIVALENTS (Date, Description of Gift, Estimated Value)
Part 2: NON-MONETARY GIFTS (Date, Description of Gift, Estimated Value)
Part 3: GIFTS WITHOUT CASH VALUE e.g., Rewards Points beyond those awarded for normal purchases and travel (Date, Description of Gift, Estimated Value)
I HEREBY CONFIRM that I have read and understand ACR’s conflict of interest policy and that my responses to the above questions are complete and correct to the best of my information and belief. I agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this policy, I will notify an ACR Board member immediately. *
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Signature: *
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