Appendix 1.3.3.1 Conflict of Interest Policy Disclosure Statement

In accordance with the Conflict of Interest Policy for Chaminade University of Honolulu, I make the following disclosure of affiliation as specified in Section 4 of the policy:

1. At this time, I am currently an officer, partner, employee or retiree of the following organization/s (if self-employed, so indicate):
2. At this time, I am a Board member, trustee, or committee member (please indicate which) of the following organizations (include both for-profit and non-profit affiliations):
3. In addition to those listed above, I have the following affiliations (including the affiliations of “related others”) as defined in Section 4 of the Conflict of Interest Policy:

I certify that I have read and understand the Conflict of Interest policy and I agree to update this form as circumstances/situations change.

Name:______________________________Signature:________________________

Date:_______________________________

(Please check one of the following)

-Board of Regent Member

-Hui Haku Senior Leadership Council

316536A
Rev 12/16/2009