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Potential Conflict of Interest Disclosure Statement

1. Contact Information *This question is required.
This question requires a valid email address.
2. Relationship to TPC: *This question is required.

1. Personal/Financial Interests in Non-Profits: Please disclose the following information, for you and your Family Members (which includes your spouse/partner; siblings; spouses/partners of siblings; ancestors; children; grandchildren; great grandchildren; spouses/partners of children, grandchildren, and great grandchildren; and any other related individual who resides in your household), with respect to each non-profit organization in Massachusetts with which you or your Family Members, to your knowledge, are involved.  

  • Member of governing board, advisory board, or policy making committee, currently or within the last 3 years
  • Significant personal relationship (donation of $5,000 or more or volunteers more than 100 hours a year)
  • Involved with the annual independent audit
  • Employee, vendor or paid/pro bono consultant
  • Other relationships (including, but not limited to, actual or potential ownership/investment interest or compensation arrangement)
2. Other Financial Interests: Please disclose the following information, for you and your Family Members, with respect to any other entity or individual in Massachusetts with which TPC currently does business or is currently negotiating a business arrangement with which you or your Family Members, to your knowledge, are involved. 
  • Member of governing board, advisory board, or policy making committee, currently or within the last 3 years
  • Involved with the annual independent audit
  • Employee, vendor or paid consultant
  • Other relationships (including, but not limited to, actual or potential ownership/investment interest or compensation arrangement)
This disclosure statement shall be kept on file with the Clerk of TPC.  If you have nothing to disclose, please write “none.”
3. Disclosures
Organization You/Your Family Member Type of Relationship
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