Wilkes University
Significant Financial Interest Disclosure Form
Name: __________________________________________________________________________
Department, Program or Center: ______________________________________________________
Title of Sponsored Project: __________________________________________________________
Name of Funding Sponsor: __________________________________________________________
Submission Date: __________________________________________________________________
Project Period:_____________________________________________________________________
Certification: I have read and understand the Wilkes University Conflict of Interest Policy
Pertaining to Sponsored Projects.
Please Respond by Inserting an “X” in the appropriate boxes:
1. Are you or any member of your immediate family (spouse and dependent children) an officer,
director, partner, trustee, employee, advisory board member, or agent of the external organization
funding this sponsored project or of any organization from which goods and services will be
obtained under the sponsored project?
yes _____ Describe in detail the nature and extent of the relationship on an attached sheet.
no _____
2. Are you or any immediate family member the actual or beneficial owner of more than five percent
(5%) of the voting stock or controlling interest of the external organization funding this sponsored
project or any external organization from which goods and services will be obtained under this
sponsored project?
yes _____ Describe in detail the nature and extent of the equity interest on an attached sheet.
no _____
3. Have you or any member of your immediate family derived income within the past year, or do you
or any member of your immediate family anticipate deriving income, exceeding $10,000 per year
from (a) the external organization funding this sponsored project or (b) any external organization
from which goods and services will be obtained under this sponsored project (including those to
which you may be subcontracting a portion of the project work)? Do not include funds that would
pay your university salary under the sponsored project budget.
yes ______ Describe the amount of the income and the reason for which it was or will be derived on
an attached sheet.
no ______
Signature______________________________________________________ Date___________________
Form developed 5/2004
