Conflict of Interest Annual Requirement Click here to view and download the PDF. Name of Associate First Last Position and TitlePractice NameDate MM slash DD slash YYYY List all Affiliated Organizations with which you are engaged and/or business enterprises in which you, or any Immediate Family Member, holds a direct or indirect Financial Interest (all capitalized terms as defined in the Conflict of Interest Policy)Please include Name of Affiliated Organization/Business Enterprise, Primary Business Address, Brief Description of the Business, and Nature of Conflict.List all personal interests or outside engagements which may pose or result in a conflict of interestPlease include Personal Interest/Outside Engagement and Nature of Conflict or Potential Conflict.List all commissions, fees, gifts & hospitality, including meals, entertainment (other than customary gifts of token value) that you or an Immediate Family Members receives from suppliers, competitors or customers of the company, or become entitled to receive, directly or indirectly, as a result of your relationship or position with the Company, that is not or will not be compensation directly related to your duties to the CompanyPlease include Date Received, Value of the item, Item Received (i.e., cash, gift certificate, restaurant dinner), and Name & Primary Address of the Individual or Company who provided the item.List all Immediate Family Members who are employed, engaged or affiliated with the Company or Affiliated OrganizationsPlease include Name and Relationship of immediate Family Member, Nature of Conflict, and Date of employment, engagement or affiliation.I have received and read Coherent’s Conflict of Interest Policy. I understand the policy, my duties and responsibilities to comply with its provisions, and the consequences of non-compliance. I certify that I am in compliance with the policy, know of no violation of or deviations from the policy, have raised all issues concerning actual or potential conflicts of interest in writing with the Human Resources Director, the Compliance Officer or Corporate Counsel, as appropriate, and that my responses to the above questions are complete and correct to the best of my knowledge. I agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this Conflict of Interest Policy, I will notify the appropriate Company representative.If a first tier, downstream or related entity of Coherent Eye Care: 1the undersigned further attests that the FDR has obtained conflict of interest statements from the FDR’s directors and employees, volunteers, and consultants. Return to Compliance Forms
