GBEAA-E ©

EXHIBIT

STAFF  CONFLICT  OF  INTEREST

CONFLICT OF INTEREST DISCLOSURE
PURSUANT TO A.R.S. §§ 38-501 to 511

(Instructions)

1.  Employees must file a Conflict of Interest Disclosure within five (5) calendar days after commencing work and at least annually thereafter, either identifying any conflict the employee or the employee's relative has or stating that the employee or the employee’s relative has no conflict.

2.  All Conflict of Interest Disclosures shall be kept on file at the District Office, 221 East Hortt Street, Fredonia, AZ  86022.

3.  It is the employee’s responsibility to update and submit to both District Legal and Human Resources Departments within fifteen (15) calendar days of any new conflict arising after the date of the most recent Disclosure.

STATEMENT OF CONFLICT

I, _____________________________________________________, do hereby indicate:

1.  That I am presently an employee of the Fredonia-Moccasin Unified School District;

2.  That I (or my relative[s]: ___________________________________________) have a substantial interest in the contract, sale, purchase, decision, investigation, or other matter by the Fredonia-Moccasin Unified School District No. 6 Governing Board as described below.

Identify the contract, sale, purchase, service, decision, investigation, or other matter in which you or your relative may have a "substantial interest" under A.R.S. §§ 38-501 to 511.  (Use as much space as necessary)

Describe the "substantial interest" referred to above.   (Use as much space as necessary) 

 

STATEMENT OF DISQUALIFICATION
To be completed if you have a conflict as identified above.

To avoid any possible conflict of interest under A.R.S. §§ 38-501 to 511, I will refrain from participating in any manner in the matter identified above.

_________________________        ______________________________________
                    Date                                                           Signature

STATEMENT OF NO CONFLICT
To be completed only if you do not or your relative does not
have a conflict of interest.

I, _______________________________, do hereby indicate that I do not have, and none of my relatives has, a substantial interest in any contract, sale, purchase, service, decision, investigation, or other matter of the Fredonia-Moccasin Unified School District.

_________________________        ______________________________________
                    Date                                                           Signature