Questionnaire

In responding to these questions, please note that a “yes” answer does not imply that the relationship or transaction was necessarily inappropriate.Are you an officer, director, employee, and/or member of a Blinded Veterans Association regional group or any other entity with which the Blinded Veterans Association (BVA) has business dealings? *

• Yes
• No

Please list the name of the regional group and other entities, the office, position, and/or type of membership held, and the approximate dollar amount of business involved with BVA for the last year:

Entity 1Name *Office, Position, Membership *Approximate Dollar *Entity 2NameOffice, Position, MembershipApproximate DollarDid you participate in raising any funds for the entities stated above (including regional groups)? *

• Yes
• No

Please state the name of the entities for which you were raising funds and an approximate dollar amount of total funds raised:

Entity 1Name *Approximate Dollar Raised *Entity 2NameApproximate Dollar Raised *Do you, or does any member of your family, have a financial interest in, or receive any remuneration or income from, any entity with which BVA has business dealings? *

• Yes
• No

Please list the names of entities in which such interest is held, the person(s) by whom such interest is held, and the nature and amount of each such financial interest, remuneration, or income:

Entity 1Name *Person *Nature *Amount *Entity 2NamePersonNatureAmountDid you, or did any member of your family, receive during the past 12 months any gifts or loans from any source from which BVA buys goods or services, or with which BVA has significant business dealings? *

• Yes
• No

List such gifts or loans as follows:

Entity 1Name of Source *Item *Approximate Value *Entity 2Name of SourceItemApproximate ValueWere you involved in any other activity during the past year that maybe interpreted as a possible conflict of interest? *

• Yes
• No

Please describe: *Acknowledgement of Truthfulness *

• I certify that the information provided in the foregoing Conflict of Interest Questionnaire is true and complete to the best of my knowledge, and that I will comply with the BVA Conflict of Interest Policy. *

Acknowledgement of Confidentiality *

• I also certify that any confidential and/or proprietary information received regarding BVA matters will not be disclosed in accordance with the BVA Confidentiality Policy. *

Digital Signature *
Submit