Burrell College of Osteopathic Medicine – Conflict of Interest

Name:*
First Last
- I am not aware of any existing or potential conflicts of interest that might impair or reasonably appear to impair my independent, unbiased judgment in the discharge of my responsibilities to Burrell College.
Signature
Date
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If you are aware of an existing/potential conflict of interest, please fill out the appropriate section below.
I disclose to Burrell College that the following existing or potential conflicts of interest might impair or reasonably appear to impair my independent, unbiased judgment in the discharge of my responsibilities to Burrell College.
Signature
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I disclose to Burrell College that a member of my family, or an organization in which I or a member of my family is an officer, director, employee, member, partner, trustee, or controlling stockholder has the following existing or potential interest that might impair or reasonably appear to impair my independent, unbiased judgment in the discharge of my responsibilities to Burrell College.
Signature
Date
Date Format: MM slash DD slash YYYY

Conflict of Interest – Staff