You must have JavaScript enabled to use this form. DOANE UNIVERSITY CONFLICT OF INTEREST QUESTIONNAIRE Pursuant to the purposes and intent of the Conflict of Interest Policy adopted by the Board of Trustees of Doane University in May, 2008 and revised in October, 2010, a copy of which has been furnished to me requiring disclosure of certain Covered Transactions by a Covered Individual. I hereby state that I or members of my family have the following affiliations or interests and have taken part in the following transactions that, when considered in conjunction with my position with or relation to Doane, might possibly constitute a conflict of interest. *A Covered Individual’s family is defined as: spouse, parent, sibling, child, grandparent, grandchild, great grandchild, in-law or domestic partner, and spouses of brothers, sisters, children, grandchildren and great-grandchildren, or step-relative of any of the above. 1. Covered Transactions Please identify any Covered Transactions. Any Covered Transactions includes: Holding, directly or indirectly, a position or a financial interest in any outside concern from which the individual has reason to believe Doane secures goods or services (including the services of buying or selling stocks, bonds, or other securities) or that provides services competitive with Doane. Competing, directly or indirectly, with Doane in the purchase or sale of property or property rights, interest, or services. Identify and describe any such interests or investments for yourself or your family. If none, please type "none" in the text field. Conflict of Interest Text Field 2. Outside Activities Please identify any outside activities. Outside activities include: Rendering directive, managerial, or consultative services to any outside concern that does business with, or competes with the services of Doane, or rendering other services in competition with Doane. Identify and describe any such activities for yourself or your family. If none, please type "none" into the text field. Outside Activities Text Field 3. Gifts, Gratuities, and Entertainment Please identify any gifts, gratuities, or entertainment, which include: Accepting gifts, excessive entertainment, or other favors from any outside entity that does, or is seeking to do, business with, or is a competitor of, Doane under circumstances from which it might be inferred that such action was intended to influence or possibly would influence you in the performance of your duties. I hereby certify that neither I, nor any member of my family, have accepted gifts, gratuities, or entertainment that might influence my judgment or actions concerning the business of Doane except as listed here. If none, please type "none" into the text field. Gifts Text Field Please identify any disclosure or use of inside information, which includes: Disclosing or using information relating to Doane’s business for my or my family’s personal profit or advantage. If none, please type "none" into the text field. Inside Information Text Field I realize that I need to make full disclosure of any situation in doubt so as to permit an impartial and objective determination. I am aware that disclosure relates not only to me, but also to any other party with whom I may have a significant relationship. I hereby agree to report to the Chair of the Doane Board of Trustees or President of Doane University any further situations that may develop before completion of my next questionnaire. In addition to the acknowledgments and affirmations made above, I further affirm that I: have received a copy of the Conflict of Interest Policy; have read and understand the Policy; have agreed to comply with the Policy; and understand that Doane University is a charitable organization and that in order to maintain its federal tax exemption, it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. Signature (Name and Position)
