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Form for Principles of Business Conduct Compliance Certificate and Conflict of Interest Disclosure Statement

This form may be completed and submitted electronically by:

  1. Selecting one of the following group names.
  • Volunteers and staff, select Operations Audit.
  • Conference organizers, select Conference Finance.



    2. Respond to each question.
    3. Enter the required information at the end of the form.
    4. Submit the form.

Principles of Business Conduct Compliance Certificate

I have read and understand the IEEE Principles of Business Conduct. I will adhere in all respects to the standards described therein. I further confirm my understanding that any violation of the IEEE Principles of Business Conduct will subject me to appropriate disciplinary action, which may include termination of my volunteer/member position or discharge from my staff position.

I certify to IEEE that I am not potentially in violation of the requirements of the program, unless I have noted that potential in a signed Statement of Exceptions (brief written description of the possible violation) attached to this Compliance Certificate.

Please answer the following:

Is a Statement of Exceptions needed?

Yes  No
 
If yes, please enter Statement of Exceptions:

 

Conflict of Interest Disclosure Statement

1. Are you or is any member of your immediate family affiliated with a business that supplies property, goods or services to IEEE or engages in any business that is competitive with IEEE or is a client of IEEE?

Yes  No
If yes, please explain:

 
2. Do you or any member of your immediate family have a direct or indirect interest in a business that supplies property, goods or services to IEEE or is in competition with IEEE or is a client of IEEE?

Yes   No
If yes, please explain:

 
3. If you answered "Yes" to Questions 1 and/or 2 above, in the past 12 months have you made a business decision on behalf of IEEE with any business, named in the responses to those questions?

Yes No   Does not apply
If yes, please explain:

 
4. In the past 12 months, have you received any compensation, loan, gift, benefit or unusual hospitality from any supplier, competitor, or client to IEEE?

Yes   No
If yes, please explain:

 
 
5. Have you received, or do you expect to receive, compensation from any unrelated organization or individual for services rendered to IEEE?

Yes   No
If yes, please explain:

 
6. Do you have any other business or personal relationships, not covered in your answers to Questions 1 through 5 above that could appear to be a conflict of interest?

Yes   No
If yes, please explain:

 

 

ATTESTATION:
I have entered required responses to the Principles of Business Conduct Compliance Certificate and to Conflict of Interest Disclosure Statement the best of my knowledge and belief.
 

Are you an IEEE Employee/Volunteer?

Yes   No

If no, please select checkbox:
I have read and understand the IEEE Code of Ethics, particularly as it relates to the potential conflicts of interest noted above.

 
Full Name
E-mail
Staff or Volunteer Position
Conference Title, Number and Year (if applicable)
IEEE Location for Staff or Address for Volunteers
City
State/Province
Country
Zip Code (Mail Code)

Telephone Number (Including Area Code or Country and City Code)

A copy of the completed form will be sent to your e-mail for your records. You will be directed to a confirmation page if your form has been submitted successfully.
Form date 12/18/10


  

 

 
 

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Report a Concern

To make an anonymous report of inappropriate financial activities involving IEEE business or compliance with IEEE principles of business conduct, file a report at Ethics Point.