MAC Annual Board Member Due Diligence Disclosure Form

Annual Board Member Due Diligence Disclosure

The Midlands African Chamber requires all board members to complete this annual disclosure form as part of our due diligence process. This form ensures compliance with legal, ethical, and governance standards and safeguards the integrity of the the Midlands African Chamber.

Please complete all sections honestly and thoroughly.

SECTION 1: GENERAL INFORMATION

First Name

Middle Name

Last Name

Position/Title on the Board

Date of Joining the Board:

Phone Number

Address

City

State

Zip Code

SECTION 2: CONFLICT OF INTEREST

Please disclose any potential or actual conflicts of interest, including any financial or business relationships that might influence or be perceived to influence your role as a board member.

Are you currently engaged in any business dealings with the Midlands African Chamber(directly or through a family member, employer, or company you control)?

Yes

If yes, please describe:

Do you or any immediate family members have any financial interest in any business or organization that has a relationship with the Midlands African Chamber?

Yes

If yes, please describe:

Are you currently serving as an officer, director, or board member for any other organization, for-profit or nonprofit?

Yes

If yes, please list the organizations and positions:

Are there any other personal, professional, or financial interests or affiliations that may pose a conflict of interest with your duties as a board member?

Yes

If yes, please describe:

SECTION 3: LEGAL AND ETHICAL DISCLOSURES

Have you been involved in any legal proceedings, investigations, or governmental actions (including bankruptcy, fraud, or criminal cases) within the past 5 years?

Yes

If yes, please describe:

Have you been charged or convicted of any crimes, including felonies, that could impact your role as a board member?

Yes

If yes, please provide details:

Are there any pending or anticipated legal actions that may affect your ability to serve on the board?

Yes

If yes, please describe:

Have you had any prior ethical violations, including those related to business practices, governance, or your duties on other boards?

Yes

If yes, please describe:

SECTION 4: CONFIDENTIALITY, CODE OF CONDUCT, AND CONFLICT OF INTEREST POLICY ATTESTATION

I understand and agree to comply with the Midlands African Chamber’s confidentiality policies and code of conduct, ensuring I do not disclose any non-public information related to Midlands African Chamber matters.

I Agree

I Do Not Agree

I confirm that I will act in the best interest of the Midlands African Chamber, avoid conflicts of interest, and uphold the Midlands African Chamber’s mission and values.

I Agree

I Do Not Agree

Attestation:
I hereby affirm that:

I have received a copy of the Midlands African Chamber’s Conflict of Interest Policy.

I have read and understand the Conflict of Interest Policy.

I agree to comply with the Conflict of Interest Policy.

I understand that the Midlands African Chamber is a charitable organization and, to maintain its federal tax exemption, it must engage primarily in activities that accomplish one or more of its tax-exempt purposes.

I Attest

I Do Not Attest

SECTION 5: SIGNATURE

By signing below, I affirm that the information provided in this disclosure form is true, complete, and accurate to the best of my knowledge. I acknowledge that failure to disclose relevant information or any falsification of information may result in disciplinary action, including potential removal from the board.

First Name

Last Name

Signature

Sign Here

Date

MAC Annual Board Member Due Diligence Disclosure Form

2025

SECTION 1: GENERAL INFORMATION

SECTION 2: CONFLICT OF INTEREST

SECTION 3: LEGAL AND ETHICAL DISCLOSURES

SECTION 4: CONFIDENTIALITY, CODE OF CONDUCT, AND CONFLICT OF INTEREST POLICY ATTESTATION

SECTION 5: SIGNATURE