Conflict of Interest Annual Requirement

  • MM slash DD slash YYYY
  • Please include Name of Affiliated Organization/Business Enterprise, Primary Business Address, Brief Description of the Business, and Nature of Conflict.
  • Please include Personal Interest/Outside Engagement and Nature of Conflict or Potential Conflict.
  • Please 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.
  • Please 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.