Board of Trustees
Annual Disclosure Form
For Trustees, Institutional Officers and Senior Staff
Please print and complete the following form and return it to the Internet Society per the instructions above. It is mandatory that we have one on file each year for each Trustee, Officer and VP.
- Is there any business relationship with ISOC between yourself or a member of your family that may represent a conflict of interest?
_____ Yes _____ No
If Yes, please list or elaborate such relationships and the details of annual or potential financial benefit as you can best estimate them. - Did you or a member of your family receive, during the past 12 months, any gifts or loans from any source from which ISOC buys good or services or otherwise has significant business dealings?
_____ Yes _____ No
If Yes, please list such loans or gifts, their source, and their approximate value. - 3. Please identify your main employer and any consulting contracts or board seats you may have with ISOC business partners, members or sponsors.
- Please identify any business relations you may have with other ISOC board members and the nature of those.
Name:
Date:
Signature:
