| Ethics Commission, North Dakota

Reporting Official's Name

Associated Entity/Organization Name

Name of Disclosing Official

Title/Position of Disclosing Official

Phone Number

Email Address

Detailed Description of Potential Conflict of Interest

Determining Body or Individual (mark appropriate box)

Self-Reporting Official

Remaining members of board, commission, committee, or legislative body

Public Official's Supervisor

Governor's Designated Ethics Officer

Appointing Official

Designated Neutral Reviewer

Provide information on the process for determination

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Certification

I certify that the information provided in this disclosure form is true, correct, complete, and of my own personal knowledge. I will fully cooperate in the process regarding this disclosure form.

Signature

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