AMP Board & Committee Governance Disclosures Submission Form

Disclosure of the following information is required of all members of the AMP Board and Committees who have decision-making responsibilities. Please answer the following questions and include the same information for persons with a close legal relationship. SECTION A: Your Employer SECTION B: Volunteer Service SECTION C: Financial Disclosures ----------------------------------------------- By submitting this form below, I: (1) acknowledge that I have received and read the Association for Molecular Pathology Statement of Fiduciary Responsibility available at http://www.amp.org/about/get_involved.cfm; (2) promise to serve AMP to the best of my ability and with the highest degree of duty, loyalty, and care; (3) promise to conduct and hold all AMP matters in confidence; (4) will neither disclose information nor distribute materials obtained; and (5) attest that I do not have any actual, apparent or potential conflicts of interest which are not listed below. I understand that it is my responsibility to inform the Executive Director in writing of any change in circumstances relating to the Statement of Fiduciary Responsibility.
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SECTION A: YOUR EMPLOYER