CONFLICT OF INTEREST QUESTIONNAIRE
for the fiscal year ending June 30, 2017

For purposes of this questionnaire:

"CASE" includes CASE itself, its Districts, CASE (Europe,) CASE (Asia-Pacific) and CASE (America Latina).

"FAMILY" is defined as your spouse, domestic partner, children (whether natural or adopted), brothers, sisters, grandchildren, stepchildren, grandparents, parents, parents-in-law and grandparents-in-law. The spouse or domestic partner of any person included within the above listing is also considered to be family.

"A MATERIAL FINANCIAL INTEREST" is defined as:

Any ownership or investment interest (including stock, options, a partnership interest, or any other ownership or investment interest) valued at more than $10,000 except equity in a publicly traded company amounting to less than a 5 percent ownership in the company;
Receipt of non-dividend compensation (including salary, consulting fees, royalty payments or other remuneration) of more than $10,000 in any 12 month period in the past three years or the expectation of such compensation in the future;
Real property, personal property, intellectual property or any other interest valued at $10,000 or more;
A position of real or apparent authority in an outside entity, such as a director, officer, trustee or partner.

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS
If you answer "yes" to a question, please provide an explanation.

Please indicate your CASE district: *

1. Do you or a member of your family serve on the board of directors (or any other governing or advisory body) of any organizations that might conduct business with or be in competition in any way with CASE? *

Yes

No

Please explain (1.):

2. Do you or a member of your family have a material financial interest in or receive remuneration from any company that conducts business with or is seeking to conduct business with CASE or may be in competition in any way with CASE? *

Yes

No

Please explain (2.):

3. Do you or a member of your family have a material financial interest in any contracts, agreements, sales, purchases, transfers, leasing arrangements, guarantees or other arrangements that may have been entered into or are contemplated being entered into by CASE since the beginning of the fiscal year under audit? Please also include any transactions that are currently pending completion. *

Yes

No

Please explain (3.):

4. Have you or a member of your family been indebted to CASE at any time since the beginning of the fiscal year under audit, or is CASE indebted to you? Please exclude amounts related to ordinary travel for CASE business and expense advances. *

Yes

No

Please explain (4.):

5. Have you, a member of your family, or a business owned by you or your family done any paid consulting with or for CASE since the beginning of the fiscal year under audit? Please also include all upcoming engagements of which you are aware. *

Yes

No

Please explain (5.):

6. Have you, a member of your family, or a business owned by you or a family member done any paid consulting for a CASE member institution or with any educational institution, professional association, or organization since the beginning of the fiscal year under audit? Please also include all upcoming engagements of which you are aware. *

Yes

No

Please explain (6.):

7. Do you have any family or business relationship with any officers, trustees or senior staff at CASE? *

Yes

No

Please explain (7.):

Name: *

Title: *

Institution: *

By checking this box you certify that your answers to the foregoing questions are correct to the best of your knowledge and belief. You also acknowledge that you have read and understand the CASE Conflict of Interest Policy and agree with the intent and spirit of the policy. *

I certify that my answers to the foregoing questions are correct to the best of my knowledge and belief. I acknowledge that I have read and understand the CASE Conflict of Interest Policy and agree with the intent and spirit of the policy.

CONFLICT OF INTEREST QUESTIONNAIRE for the fiscal year ending June 30, 2017

CONFLICT OF INTEREST QUESTIONNAIRE
for the fiscal year ending June 30, 2017