Conflict of Interest Disclosure

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Conflict of Interest Disclosure

WHEREAS, I, _________________________, am a member of the Board of Directors of _________________________, and, WHEREAS, the Board of Directors of ________________________ will consider the following issue: _________________________, and, WHEREAS, I have a conflict of interest in that, _________________________, I herewith notify the board of such conflict, and recuse myself from the consideration and discussion of _________________________, and request that this disclosure be made a part of the records of the _________________________ Corporation.

Dated: ______________________

__________________________

_________________________

Receipt of this instrument is acknowledged on ________________________:

__________________________

Corporate secretary of _________________________