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Conflict of Interest Questionnaire 2017

  1. Explanation of Form & Instructions

  2. Pursuant to the purposes and intent of the policy adopted by the Board of Directors of the Naperville Heritage Society (“Society”) requiring disclosure of certain interests, a copy of which has been furnished to you, you hereby state that you or members of your immediate family (spouse and children at home) have the following affiliations, interests or relationships and/or have taken part in the following transactions that, when considered in conjunction with your position with or relationship to the Society, might possibly constitute a conflict of interest.

    Check “No” where applicable, or explain any possible conflicts of interest on this form. All possible conflicts of interest that existed or that exist since the filing of your last Conflict of Interest Statement, or since the beginning of your Board of Director tenure, employment, independent contractor or agency relationship if no prior Conflict of Interest Statement was filed, should be reported on this form. In addition, you must report to the Executive Committee of the Naperville Heritage Society any further situation, activity or conduct that may develop before completion of the next questionnaire.

  3. Outside Interests

  4. Do you hold, directly or indirectly, a position or material financial non-publicly traded interest in any outside entity with which you have reason to believe the Society does business, including obtaining goods or services, or that provides services competitive with the Society? A “material” financial interest is one which involves or has a fair market value of more than $1,000.*

  5. Are you engaged in any "for profit" business outside of your duties at the Society, which in any way competes with activties at the Society?*

  6. Are you an officer or director of any company or organization other than the Society? (This includes only for-profit or not-for-profit organizations that do business with the Society.)*

  7. Do you have any personal loans, advances or borrowing from any customer or supplier who also does business with the Society? (Excluding charge cards and personal or mortgage loans at market rates at financial institutions, such as banks, finance companies, insurance companies and savings and loan associations.)*

  8. Do you compete, directly or indirectly, with the Society in the purchase or sale of property rights, interest or services?*

  9. Do you render managerial, consultative or other services to or on behalf of any outside entity that does business with or competes with the services of the Society?*

  10. Do you employ or otherwise retain personnel of the Society for work on non-corporate business done outside of the Society?*

  11. Have you used property of the Society to conduct business that is not Society business without prior approval of the President & CEO of the Society?*

  12. Have you accepted assignments outside of the Society, either as an employee or as a contractor, over and above your primary or full-time assignment with the Society?*

  13. Do you hold an elected or appointed office or other position of public responsibility that serves residents in the Society’s market area?*

  14. Inside Activities

  15. Do you employ or otherwise retain any member of your immediate family or other individual with whom you have a business or personal relationship in your area of direct responsibility within the Society? Have you attempted to influence the Society concerning the employment or retention of any immediate family member or other individual with whom you have a business or personal relationship?*

  16. Have you disclosed or used privileged information of the Society for any personal profit or advantage or the profit or advantage of a family member or individual with whom you have a personal relationship?*

  17. Gifts, Gratuities & Entertainment

  18. Have you accepted gifts, entertainment, discounts or other favors from any outside entity that does or is seeking to do business with, or is a competitor of, the Society, 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? This does not preclude reasonable entertainment by suppliers or prospective suppliers when the value of such activity does not exceed $100.*

  19. Have you or your immediate family accepted any gifts, favors or benefits valued in excess of $100 from customers, suppliers or agents of the Society?*

  20. Explanation of Conflicts of Interest

  21. I have read and understand the Institutional Code of Ethics and will comply with my responsibilities as a board member.

  22. Disclaimer

  23. By submitting this form, I hereby state that the information contained herein is true and accurate to the best of my knowledge and belief as of the submission date.

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  25. This field is not part of the form submission.