ࡱ> NPM 9bjbj .FeeS(((8`L4(.L$!lggg^   gL g   PrjNF t0 !l!  !gg gggggeggggggg!ggggggggg : APPENDIX C REPORT OF ACTIVITIES AND RELATIONSHIPS WITH BUSINESSES SPONSORING UNIVERSITY ACTIVITIES OR DOING BUSINESS WITH THE UNIVERSITY Complete this form if you answered YES to one or more of Questions 5-8 on the Annual Conflict of Interest/Commitment Statement-Attachment 1. Attach separate sheets and give the answer number for which additional information is provided. Use a separate form to report relationships with each enterprise or corporation. Name:  FORMTEXT       Banner ID:  FORMTEXT       Campus Address Room:  FORMTEXT       Building:  FORMTEXT       Local Address Street:  FORMTEXT       City/State:  FORMTEXT       Zip Code:  FORMTEXT       Rank:  FORMTEXT       Title:  FORMTEXT       Department:  FORMTEXT       Unit:  FORMTEXT       1. Do any of your University activities sponsored by this enterprise involve technology owned by or contractually obligated to this enterprise?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES provide a discussion of the actions or safeguards you will take to prevent your activities from affecting your objectivity as a University employee or will otherwise protect University interest.  FORMTEXT       Complete statements 2-4 and answer question #7 (of this form) if you answered YES to Question 6 on the Annual Conflict of Interest/Commitment Statement-Attachment 1. 2. Type of Board, Board Committee, or executive position held by you or your family member.  FORMTEXT       3. Describe the responsibilities of this relationship.  FORMTEXT       4a. Describe the University activities funded by this enterprise in which you are a participant.  FORMTEXT       4b. Specify the type of funding, gifts, gratuities, fees or other benefit/compensation (direct or deferred) received by you (other than occasional meals, complementary copies of textbooks, etc.) from the enterprise during the last 12 months.  FORMTEXT       Complete the following and answer Item #7 if you answered YES to Questions 7 or 8 on the Annual Conflict of Interest/Commitment Statement-Attachment 1. 5. If you answered YES to Question 7, complete the following. (a) Describe the nature of the financial interest in the enterprise.  FORMTEXT       (b) If you or a member of the family has a financial interest, other than a consulting relationship, is the interest or shares total market value greater than $5,000 or does the interest or shares represent an ownership interest of 5% or more?    U V  4 6 J L N X Z \ ` ̵¦̍¦̀̚¦šs¦j\hG5UjhG5UjthG5UhGjhGUjhG5UmHnHujhG5UjhG5U hG5 hL=t5hBD h7hL=thL=th7h>5\ hL=t5\h7hL=t5\-  | ^ `   X Z 12 ^`gdGgdG 7$8$H$gdL=t $7$8$H$a$gdL=t 0 2 F H J T V t v      , . B D F P R v x ѢѢjhG5UjhG5UjhGUj,hG5UjhG5UjDhG5UjhG5UmHnHujhG5U hG5hGjhG5U2 )*+.012   ļɢnZ&jh h\J 5U\mHnHu!jh h5U\h h\J 5\jh h\J 5U\jphUhL=t h7hL=tjhUhdwjhdwU hdw5hJ:hL=t5 hL=t5hGjhG5UmHnHujhG5UjhG5U!2`bdfFHJ 7$8$H$gdL=t Bbf 468BDFHJѻ~td] h\J 5>*jh\J h5Uh(h\J 5>* hL=t5>*hzhL=t5jh\J 5UmHnHujXh\J h5U h\J 5jh\J 5UhJ:hL=t5 h\J 5\ hL=t5\h7hL=t5\h7h\J 5>*\h\J 5>*\hdw5>*\h hdw5\ cdvoh^TMTMTH hL=t5 hL=t5\h7hL=t5\h(hA5>* hA5>* hf5>*jhG5UmHnHujh\J hG5U hG5jhG5U h7hL=thL=thJ:hL=t5h(h\J 5>* h\J 5>* hL=t5>*hzhL=t5jh\J 5UmHnHujh\J 5UjDh\J h5U(,*,.,-D-F-J--. 7$8$H$`gdL=t 7$8$H$^`gdL=t7$8$H$^`gdL=t87$8$H$^8`gdL=t 7$8$H$gdL=t&'  lp,,,,,$,&,*,.,---2-4-6-@-B-F-H-J----. . ....ꏺzj hAh5U hL=t5hL=tj hAh5UjhAh5UU hBD5 h7hL=tjhA5UmHnHuj0hAh5UjhA5U hA5hJ:hL=t5hJ:hA5. FORMTEXT       (c) What is the duration of the sponsored research, testing or service, of your consulting contract (if applicable)?  FORMTEXT       (d) Describe the scope and nature of your duties as a consultant (if applicable).  FORMTEXT       6. If you answered YES to Question 8, complete the following. (a) Describe the University position you hold in which you supervise, select, or evaluate services provided to the University by the enterprise or in which you refer University business to the enterprise.  FORMTEXT       (b) List the services/business involved.  FORMTEXT       (c) Does the enterprise compete with services provided by the University?  FORMCHECKBOX  YES  FORMCHECKBOX NO If YES, describe these services. 7. For all "yes" answers above provide a discussion of the activities and actions or safeguards you propose to take to prevent your activities from affecting your objectivity as a University employee or will otherwise protect the University's interests.  FORMTEXT       SIGNATURES: I certify that all of the above information is correct and that I will promptly update information as changes occur. __________________________________________ ________________________ Employee Signature Date __________________________________________ ________________________ Department Chair Date __________________________________________ ________________________ Dean (where applicable) Date __________________________________________ _______________________ Standing Committee on Conflicts of Date Interest and Commitment (where applicable)     Confidential Annual Conflict Assessment Personnel Record 10/31/14 ....40^0`0d00000|11142628244\4^4gdL=t 7$8$H$^gdA7$8$H$^`gd+7$8$H$^`gdL=t 7$8$H$gdL=t 7$8$H$`gdL=t...206080L0N0P0Z0\0`0b0d000000000000b1x1z111111111111ַ೬峨xmbjh hUj hUhJ:h+5 h7hAjhAUmHnHuj~ hUjhAUhA h7hL=thL=tjhA5UmHnHuj hAh5UjhA5U hA5hJ:hL=t5h(hL=t5>*hqhA5&1111102426282244464J4L4N4X4Z4`4b4z4|4f5h55566 6*6.6066666666667777777777V8X8谨속삨삨h3 h7hG h35 hL=t5hjhL=t56 h356h3hL=t5 h7hAjhAUmHnHuj hUh(hL=t5>*OJQJ^JhJ:hL=t5hAhL=t h7hL=tjhAU3^4`4b4z4|4f5h55*6.60666677777X889 9 99gd@ 7$8$H$gdL=t H7$8$H$gdL=t 7$8$H$gdL=tX88888889999 9999999999999Ⱥh9}hGhfh>hf56CJaJhFjhFU h8ohL=t hL=t5h3hL=t5h3hL=t h7hL=thJ:hL=t5999999p99999999gd@ ,1h/ =!"#$% tDText1tDText3tDText2tDText2tDText3tDText2tDText2tDText2tDText2tDText3tDText2tDeCheck1tDeCheck2tDText9vDText10vDText11vDText12vDText12vDText14vDText15vDText16vDText17vDText18vDText19tDeCheck3tDeCheck4vDText20^ 02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ L=tNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4@4 >Header  !4 @4 >0Footer  !6o6 G0 Footer CharCJaJH@"H G Balloon TextCJOJQJ^JaJNo1N GBalloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] F GGRRRU .1X89 !2.^499 " )5;HTZy (.;GM  GSY     %   . : @ p |  -9?FFFFFFFFFFFG G FFFFFFFFFFFG G F8@0(  B S  ?Text1Text2Text3Check1Check2Text9Text10Text11Text12Text14Text15Text16Text17Text18Text19Check3Check4Text20H  / q . /  Z &  A  @P  GZ   &  . A p  . . -@BB)*&>P . . BB)*J[? b} @F\J PD,igL=tdwP|3 9}clBD+AsxGx>fp@|  @ @,@,UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"hH*H*yyr43QHX ?L=t*!xx  APPENDIX CingramnYvonne L. HalleyOh+'0@x    (08 APPENDIX CingramnNormalYvonne L. Halley2Microsoft Office Word@F#@SN@SNy՜.+,0 hp  (Ӱԭ A & T State University  APPENDIX C Title  !"#%&'()*+-./0123456789:;<>?@ABCDFGHIJKLORoot Entry FpБNQData $1Table,!WordDocument.FSummaryInformation(=DocumentSummaryInformation8ECompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q