I acknowledge that I have received a copy of the Conflict of Interest Policy ("Policy") of the Louisiana Academy of Family Physicians ("Academy"), and that I have read, understand and agree to comply with the Policy.

In accordance with the Policy, I hereby disclose and make a matter of record the potential conflicts of interest set forth on the attached Annual Conflict of Interest and Disclosure Information Form. I understand that it is my duty to disclose any of the following with respect to myself, and to update this disclosure as circumstances warrant:

1. An ownership or investment interest in any entity (other than a 5% or less ownership in a publicly-traded corporation) with which the Academy has a Transaction;
2. A compensation arrangement with the Academy or with any entity or individual with which the Academy has a Transaction;
3. A position in a public office or institution, whether appointed, elected or employed, which will require participation in matters involving the Academy;
4. A position as an uncompensated consultant, officer, committee member or board member of any entity with which the Academy has a Transaction;
5. Any other interest which may compete with or conflict with the interests of the Academy (e.g., a leadership position in a chapter or other entity with respect to activities that may be competitive with those of the Academy); or
6. I become Aware that a member of my Family has a Personal or Private Interest.