Ambassador Forms-Conflict of Interest and Disclosure Form

Please initial in the space at the end of Item A and complete Item B, whichever categories are appropriate; and sign and date the statement and return it to the requesting party.

Item A. I am not aware of any relationship or interest or situation involving my family or myself which might result in, or give the appearance of being, a conflict of interest between such family member or me on one hand and DONA International on the other. If this applies, please initial here:

Item B. The following may be relationships, interests or situations involving me or a member of my family that I consider might result in or appear to be an actual, apparent or potential conflict of interest between such family members or myself on one hand and DONA International on the other. If this applies, please initial here:

For-profit corporate directorships, positions and employment with:

Nonprofit trusteeships or positions:

Memberships in the following organizations:

Contracts, business activities and investments with or in the following organizations:

Other relationships and activities:

My primary business or occupation at this time is:

I have read and understand DONA International’s conflict of interest policy and agree to be bound by it. I will promptly inform the President of DONA International of any material change that develops in the information contained in the foregoing statement.

Name

First Last

Consent

I agree to the privacy policy.

Date

Conflict of Interest and Disclosure Form

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