CONFLICT OF INTEREST DISCLOSURE STATEMENT

I acknowledge I have read the policy and procedure regarding conflict of interest and the procedure for disclosure. I understand that if I have an outside relationship, personal, professional or otherwise, with a client/patient, vendor or potential business associate, I must disclose the nature of that relationship to my supervisor as soon as the relationship is established. I do understand that I forfeit any voting privileges, decision making capacity and input any activities associated with the said relationship.

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