PACT Charter School Board and Committees
Annual Conflict of Interest Statement

Directions: Please print while completing this form, sign, and date it, and return it to the Chairperson of your committee. This form will be completed in June each school year (or as soon as a new member is installed). If a person is a member of multiple committees, a separate form must be completed for each committee. Forms are to be kept on file by the Committee Clerk.

The undersigned person acknowledges receipt of a copy of the current PACT Charter School “Conflict of Interest Policy.”

By my signature below, I acknowledge my agreement with the spirit and intent of these documents, and I agree to report to committee chairperson any possible conflicts (other than those stated below) that may develop before the completion of the following annual statement.

Please check one:

_____ I am not aware of any conflict of interest, and I will conduct myself within the expectations outlined. 

_____ I have a conflict of interest in the following area(s), and I will conduct myself within the expectations outlined: 

Committee: ______________________________________________________________________________________

Signed: _________________________________________________________________________________________

Date: ___________________________________________________________________________________________

Print full name here: _______________________________________________________________________________

This Annual Statement shall apply to all members elected and appointed committees. It also includes officers and administration of PACT Charter School, beginning with their membership or employment.