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BLUE SLOPE COUNTRY MUSEUM, INC.
Statement of Affiliation and Conflict of Interest Disclosure

Name

Relationship to BSCM, Inc.

1. Please list any organization with which you or any member of your immediate family has an official position as Officers, Directors and Key Employees.

Organization Position Person Involved (relationship)

2. Please list any ownership or other financial interest that you or any member of your immediate family have with any entity that serves as a current vendor to BSCM, Inc.

Organization Position Person Involved (relationship)

Please complete next page.


BLUE SLOPE COUNTRY MUSEUM, INC.
Statement of Affiliation and Conflict of Interest Disclosure
Page 2

Name

3. Please list any collections that you or any members of your immediate family maintain.

Collection Types of items Number of items

REMINDER: Per its policies, BSCM, Inc.'s Directors, Officers, and Key Employees shall strive to avoid creating even an appearance of impropriety that would have an adverse effect upon the BSCM, Inc.'s reputation. If there is a matter of potential conflict of interest or duality of interest it is your obligation to disclose the facts to BSCM, Inc., abstain from voting, and refrain from using your personal influence on the matter even if you have no financial interest affected by the transaction.

I herby certify that the information set forth on this form is true and complete to the best of my knowledge. I have reviewed and agree to abide by the Conflict of Interest Policy of the Blue Slope Country Museum, Inc. I will update this statement of affiliation form if relevant circumstances change.

Signature Date

Printed Name


BLUE SLOPE COUNTRY MUSEUM, INC.
Statement of Affiliation and Conflict of Interest Disclosure
Page 3

Note: Definition of Family Member

  • Spouse, Domestic Partner
  • Ancestors
  • Brothers and Sisters (whether whole or half blood)
  • Children (whether natural or adopted or step-children)
  • Grandchildren
  • Great Grandchildren
  • Spouses of brothers, sisters, children, grandchildren, or great grandchildren

Note: Definition of Types of Items

  • Actual artifacts
  • Historical books, journals, or printed materials
  • Photographs, photographic slides, illustrations, artistic work
  • Recording of spoken word, music, visual
  • Other pertinent items

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