Board of Directors Statement

Step 1 of 2

Board Of Directors / PAC Conflict of Interest Disclosure Statement

I affirm that I have read and understand the Disability Rights North Carolina (DRNC) Board of Directors/PAIMI Advisory Council (PAC) Conflict of Interest policy and that I will abide by the terms of this policy at all times during my tenure as a member of DRNC’s Board of Directors/PAC. I understand and agree that my election to the Board of Directors/PAC carries with it the legal and fiduciary responsibility to act on all matters affecting DRNC in good faith with a view to the interests of DRNC, placing those interests above any personal interest I may have on any matter at issue. I also understand and agree that, in discharging my responsibilities as a director, I will exercise that degree of diligence, care, and skill which an ordinarily prudent person would exercise in my position under similar circumstances.

Consistent with policies established by DRNC, I hereby certify that the following is a true and complete disclosure of my relationships, if any, to affiliations, businesses, agencies, organizations, or other groups which have the potential of creating an actual or apparent Conflict of Interest in carrying out my responsibilities as a director/member of DRNC.

“Conflict of Interest” is a conflict between my private interests and my official responsibilities as a director/member of DRNC. A conflict of interest arises when I have a private interest that reduces the likelihood that my participation can be exercised impartially in the best interest of DRNC.

“Immediate Family member” means a person related to as a spouse or similar domestic partner; parent or step-parent; sibling (including brother-in-law or sister-in-law); or child or stepchild.

Initial as applicable

Financial Conflict of Interest

Financial Conflict of Interest: I am (or my immediate family member is) an employee, officer of director, or have an ownership interest of 10% or more in the following for profit business(es), other not-for-profit organization(s), or a governmental agency(ies) which provide a service to persons with disabilities that a reasonable person might consider having the potential to create a conflict of interest in fulfilling my duties as a director/member of DRNC (include name of business, organization or agency; type of service (whether paid or volunteer) and the relationship that creates a conflict of interest). I further understand and agree that I am obligated to abstain from debating and voting on any issue related to said conflict of interest:

Initial for a Financial Conflict of Interest

Service Conflict of Interest

Service Conflict of Interest: I am (or my Immediate family member is) an employee, officer, or director of the following agency(ies) or organization(s) which is primarily related providing a service to persons with disabilities (include name of agency or business; type of service and the relationship that creates the conflict of interest). I further understand and agree that I am obligated to abstain from debating and voting on any issue related to said conflict of interest:

Initial for a Service Conflict of Interest

Initial for No Conflicts of Interest

No Conflicts of Interest: Neither I, nor any of my immediate family members, is an employee, officer, director, or has a significant ownership interest in any business(es), organization(s), agency(ies), or group(s) providing any type of service that might create the appearance of a conflict of interest. I further understand and agree that, should I become aware of any actual, potential, or perceived conflict of interest, I am obligated immediately to disclose such conflict of interest and abstain from voting on any issue related to said conflict of interest.

Signature(Required)

First Last

Date(Required)

Disability Rights North Carolina Confidentiality Agreement

I recognize and acknowledge that the DRNC Board of Directors and PAIMI Advisory Council (PAC) will be exposed to information that is confidential, privileged or proprietary in nature. I will not disclose or discuss confidential information, including personnel and financial information, with anyone without express written permission or authorization from the CEO of DRNC. I will only use confidential information as necessary to perform my duties to DRNC. I understand that I will be responsible for the misuse or wrongful disclosure of confidential information and for failing to safeguard confidential information.

I will not share, misuse, or be careless with confidential information. I will take care to ensure that unauthorized individuals do not overhear any discussion of confidential information and that documents containing confidential information are not left in the open or inadvertently shared.

I will report activities by any individual or entity that may compromise the confidentiality of information.

I understand that these obligations will continue after my affiliation with DRNC terminates, and agree that confidential information must be kept confidential both during and after my service to DRNC. I will return materials containing confidential information at the time of expiration of my service.

I understand that unauthorized disclosure of confidential information is a serious violation of the DRNC Board of Directors’/PAC policies and will subject me to appropriate disciplinary action, including removal as a director. In addition, violations of this policy may also result in personal liability, and DRNC may initiate legal action as circumstance may warrant.