Conflict of Interest

Annual Conflict of Interest Disclosure Form

The following information is presented in compliance with the Conflict of Interest Policy adopted by the Board of Trustees. This form is to be completed and filed with the Secretary of the Board of Trustees of Philadelphia Ballet Association (hereinafter called “Ballet”) by each Trustee and non-Trustee member of the Finance Committee or any Trustee committee or subcommittee (hereinafter called “Trustee”) and by each Officer and member of the Ballet’s Senior Staff (hereinafter called “Officer”) each year.

I.
I, the undersigned, being a Trustee or Officer of the Ballet, hereby state that to the best of my knowledge except as noted below:

I do not have an official relationship with any entity that transacts business with the Ballet.⁽¹⁾
I, as an individual, do not transact any business with the Ballet for which I receive remuneration (except, in the case of Officers, for compensation paid with respect to employment with the Ballet.)
No member of my family (spouse, parents, siblings or children) is in the employ of the Ballet; has an official relationship with any entity that transacts business with the Ballet; or transacts business with the Ballet for which s/he receives remuneration.⁽¹⁾
I do not own any investments, other than a permitted investment, or have any interest or relationships which might be affected by investment decisions of the Ballet. A permitted investment means the ownership of (a) shares or the rights to purchase shares of any publicly traded stock so long as the investment in such stock is less than 10% of the outstanding voting shares; (b) shares of mutual funds; (c) an interest in a blind trust; or (d) any debt instruments of publicly held companies.

(1) In this context, official relationship means serving as an officer, director, employee, partner, proprietor or owner of 10% or more of the stock of an entity which does business with the Ballet.

I.*

Exceptions to the above statements (including amounts received from the Ballet in the prior year):

II.*

I am a Trustee, Director or Officer of the following for-profit and non-profit organizations:

III.
I agree that if circumstances change or information comes to my attention such that the foregoing information is no longer accurate, I will immediately make full disclosure thereof to the Secretary of the Board of Trustees and will answer any relevant questions the Board may have with respect to any actual or potential conflict of interests. I understand that all such information will be held in confidence by the members of the Board, unless the best interests of the Ballet dictate otherwise and a majority of the members of the Board of Trustees votes in favor of further disclosure.
IV.
I agree that all discussions at Board and committee meetings, as well as information distributed at such meetings, will remain confidential unless otherwise noted in minutes.
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- I agree to submit this form electronically. By checking this box, I certify that my answers are correct and complete to the best of my knowledge.

Conflict disclosure form (to download and print)

Annual Conflict of Interest Disclosure Form

Conflict of Interest

III.

IV.

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