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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> empp..:4r1 <br /> a"`s�'gav <br /> 4, NC DEPARTMENT OF PUBLIC SAFETY , <br /> 0-,7 '' NOT FOR PROFIT <br /> DPS CONFLICT OF INTEREST POLICY STA'l EMENT <br /> The following serves to identify and document any personal interest staff members, <br /> officers, and members of the Board of Directors may have This document is also to be <br /> used to disclose any transactions that may result in personal,financial,professional <br /> and/or political gain at the expense of DPS. The statement requires that all personal <br /> relationships that may inappropriately influence (bias) actions be disclosed <br /> Relationships be it personal,financial,professional and/or political are required to be <br /> disclosed to DPS. Conflict means a conflict or the appearance of a conflict between the <br /> private interests terests and official cial responsibilities of a person in a position of trust Persons <br /> in a position of trust include staff members or the Board of Directors. <br /> Private, nonprofit entities shall make full disclosure by notice in writing to the full <br /> Governing Board/Council all conflicts of interest, if"yes" is answered to any of the <br /> following: (Check all that apply) <br /> YES NO <br /> L A Board member is related to a staff member. ❑ <br /> 2. A staff member in a supervisory capacity is related to another staff El <br /> member whom he/she supervises. <br /> 3. A staff member is related to another staff member. ❑ }g <br /> 4. A board member or staff member has or may have personal, ❑ <br /> financial,professional,and/or political gain at the expense or <br /> benefit of the private,non.rof t entit,; <br /> 5. There is a business entity in which a staff,board, or family member Q ►1 <br /> participates that may be viewed as having direct or indirect <br /> influence over the private,nonprofit entity's business. <br /> 6. A staff•;board,or family member may be viewed as having direct <br /> or indirect financial gain from personal or business <br /> investments/interest in real property held by that staff,board,or <br /> family member.' <br /> 7. A staff or board member received honorarium or other <br /> compensation outside of the scope of employment/operations with <br /> the private,nonprofit entity that creates or appears to create bias. <br /> 8. A staff or board member secured employment with a competitor or <br /> other similar private,nonprofit entity. <br /> 9. Ongoing,paid consulting work outside of the staff member's ❑ <br /> current employment or board member's with your private, <br /> nonprofit entity exists. <br /> Form DPS 13 001 Not for Profit.DPS Conflict of Interest Policy Statement <br /> Form structure last revised July 2014 <br /> NC Department of Public Safety Page 2 of 3 <br />