NSATA Conflict of Interest Policy

First and Last Name *

Capacity Served *

Executive Board

Committee Member

Staff/Other (List Position)Staff/Other (List Position)

Have you or any of your affiliated persons* provided services of property to the NSATA in the past year? *

Yes

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 wit that person: *

Have you or any of your affiliated persons purchased services or property from the NSATA in the past year? *

Yes

If yes, please describe the purchased services or propery and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

Please indicate whether you or any of your affiliated persons had any direct or indirect interest in any business transaction(s) in the past year to which the NSATA was or is a party? *

Yes

If yes, describe the transaction(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

Were you or any of your affiliated person indebted to pay money to the NSATA at any time in the past year (other than travel advances or the like)? *

Yes

If yes, please describe the indebtedness and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

In the past year, did you or any of your affiliated persons receive, or become entitled to receive directly or indirectly, any personal benefits from the NSATA or as a result of your relationship with the NSATA, that in the aggregate could be valued in excess of $1,000, that were not or will not be compensation directly related to duties to the NSATA? *

Yes

If yes, please describe the benefit(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

Are you or any of your affiliated persons a party to or have an interest in any pending legal proceedings involving the NSATA? *

Yes

If yes, please describe the proceeding(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

Are you aware of any other events, transactions, arrangements or other situations that have occurred or may occur in the future that you believe should be examined by the NSATA's Executive Board in accordance with the terms and intent of the NSATA's conflict of interest policy? *

Yes

If yes, please describe the situation(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person: *

*Per this document, "affiliated persons" shall 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 are employed by, or are, directly, or indirectly, a debt holder
or the beneficial owner of any class of equity securities; and
c. any trust or other estate in which you have a substantial beneficial interest or as to which
you serve as a trustee or in a similar capaity.

I hereby confirm that I have read and understand NSATA'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 the NSATA President immediately. *

Agree

Signature *

Clear

Date