CONFLICT OF INTEREST FORM. A [board member/employee] of Academy (the “Academy”), being first duly sworn, depose and say that I have read the Academy’s Conflict of Interest Policy and the provisions of Act 317 of 1968 (MCL 15.321, et seq.) (“Act 317”), attached hereto, and other Michigan ethics or conflict of interest statutes, which may be applicable to my performance as a board member/employee of the Academy, and understand the terms of the Policy and Act 317 and further say that: 1) I am not in violation of the Policy, Act 317 or any such applicable ethics or conflict of interest statutes; 2) I agree to fully comply with such terms; and 3) I will notify the Chairman of the Academy Board and Secretary if at any time that I fail to comply with the provisions of the Policy, Act 317 or any such applicable ethics or conflict of interest statutes. [signature] Name of Academy Board Member or Employee Notary Subscribed and sworn to before me this day of , 20 . Notary Public My Commission Expires: ACT 317 of 1968 (MCL 15.321, et seq.)
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Sources: Public School Academy Contract, Public School Academy Contract