ࡱ> 574` Pbjbj *P .6 6 6 6 B .T2j j j j j j j j $h j j j j ' ' ' j j ' ' ' :,j ^ @B+6 C $0TMR ( j > ,' $ j j j ' j j j T ... $... ... 51 Significant Financial Interest Disclosure Form *This form is presently required only if you have financial interests to disclose. Faculty/Staff Name _________________________________ Dept _____________________ Sponsoring Agency _________________________________ Proposal # ________________ Proposal Title __________________________________________________________________ I am disclosing all significant financial interests in the sponsoring entity that may present an actual or potential conflict of interest in the event that I become engaged in research in a project sponsored by that entity. I enclose supporting documentation that identifies the business or entity involved and the nature and amount of the interest in a sealed envelope marked Confidential. These records will be retained by the Office of University Research until three (3) years after the termination or completion of the award to which they relate or the resolution of any government action involving those records. Check all of the following that apply: _____ Salary or other payments for services (e.g., consulting fees or honoraria), _____ Equity interests (e.g., stocks, stock options, or other ownership interests), and _____ Intellectual property rights (e.g., patents, copyrights, and royalties from such rights). _____ Other significant financial interests of the investigator or his/her family that could affect or be perceived to affect the results of the research or educational activities proposed for funding. ** Significant financial interest is defined as an equity interest that, when aggregated for the investigator and the investigators spouse and dependent children, meets the following criteria: Exceeds $10,000.00 in value as determined through reference to public prices or other reasonable measures of fair market value or Constitutes more than a five (5) per cent ownership interest in any single entity. Further, I agree: To update this disclosure during the period of this award. To cooperate in the development of a Conflict of Interest Resolution Plan. To comply with the conditions of the plan to manage, reduce or eliminate actual or potential conflicts of interest. If an agreement cannot be reached, I understand that the University may disclose the conflict of interest to the sponsor, or at its option, decline the award. I certify that I have disclosed all aspects of any financial interests which could reasonably be expected to influence the Conflict of Interest Review Committees decisions. Signed ______________________________________ Date ___________________________ University Use Only I have reviewed this Disclosure: a) ___ I do not consider a Conflict of Interest exists. b) ___ A Conflict of Interest appears to exist: referred to CIRC. By ________________________ Signature ____________________ Date ________ J , Q.2OPh`#5CJ\ h`#CJh`# IJ? @   , -  9 :  N^ & FP;PQOcHIJK,$d%d&d'd-DM NOPQ &d P h^h & F8^8KLMNOP8^8(/ =!"#$% D@D NormalCJOJQJ_HmH sH tH :@: Heading 1$@&5\DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 2B@2 Body TextCJP IJ?@,-9: N;P Q O c H I R y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0y0R y0P KP P yPyHFy"FyL)F R  R =*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace HNR O R  H O R I) *'/rCh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h ^`OJQJo(h pp^p`OJQJo(oh @ @ ^@ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h PP^P`OJQJo(oh   ^ `OJQJo(*'/I)                  `# R @ P @UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New;Wingdings"h2&2&W   24K K 2QHP? 2HLouisiana Tech University Significant Financial Interest Disclosure FormRobert GraftonElizabeth Womack  Oh+'0$0D `l    L51 Significant Financial Interest Disclosure FormRobert Grafton Normal.dotElizabeth Womack2Microsoft Office Word@@N@B+@B+ ՜.+,0H hp  )51K  I51 Significant Financial Interest Disclosure Form Title  !"#%&'()*+-./01236Root Entry FyB+8Data 1TableWordDocument*SummaryInformation($DocumentSummaryInformation8,CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q