Prior to filling out the form, please read the Conflict of Interest Policy. All board of directors must fill out the disclosure form annually to attest to policy compliance.

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I have read and understand IRSII's Conflict of Interest Policy and acknowledge the following: *

• I will comply with the policy.
• I have indicated below, to the best of my knowledge, financial, professional and/or personal relationships that could give rise to a conflict of interest as defined by the policy.
• I declare no conflicts of interest.

I declare the following as actual, possible, or perceived conflicts of interest. *

If conflicts do not exist, put NA.

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