[name of organization]
GIFT POLICY AND DISCLOSURE FORM
As part of its conflict of interest policy, ____________ requires that directors, officers
and employees decline to accept certain gifts, consideration or remuneration from individuals or
companies that seek to do business with ____________ or are a competitor of it. This policy and
disclosure form is intended to implement that prohibition on gifts.
“Responsible Person” is any person serving as an officer, employee or a
member of the board of directors of ____________.
“Family Member” is a spouse, domestic partner, parent, child or spouse of
a child, or a brother, sister, or spouse of a brother or sister, of a
“Contract or Transaction” is any agreement or relationship involving the
sale or purchase of goods, services or rights of any kind, receipt of a loan
or grant, or the establishment of any other pecuniary relationship. The
making of a gift to ____________ is not a “contract” or “transaction.”
Prohibited gifts, gratuities and entertainment. Except as approved by the
Chairman of the Board or his designee or for gifts of a value less than $50
which could not be refused without discourtesy, no Responsible Person or
Family Member shall accept gifts, entertainment or other favors from any
person or entity which:
Does or seeks to do business with ____________ or,
Does or seeks to compete with ____________ or,
Has received, is receiving, or is seeking to receive a Contract or
Transaction with ____________.
I certify that I have read the above policy concerning gifts, and I agree that I will not accept gifts,
entertainment or other favors from any individual or entity, which would be prohibited by the
above policy. Following my initial statement, I agree to provide a signed statement at the end of
each calendar year certifying that I have not received any such gifts, entertainment or other
favors during the preceding year.