Annual Disclosure of Associations

I,
Name
First Last
hereby acknowledge my association with the following organizations that may affect my participation in certain Florida Developmental Disabilities Council, Inc. activities:
Names of Organization
Any office or position held
I further acknowledge the following list of relatives and other individuals with whom I am associated who could potentially benefit from activities or decisions of the Council.
Name of Person
Relationship
*
I certify that all information provided as part of this form is true and correct to the best of my knowledge.
By selecting the "I Accept" button, I am signing this form electronically.*
I Accept
I understand that completion of this form does not allay my responsibilities to disclose, in a timely manner, any potential conflicts of interest or relationships that may give rise to a conflict of interest as set forth in the Bylaws of the Council.
Signature*
Date
MM slash DD slash YYYY
Name
First Last

I,