As a member of the Executive Board of the Alabama Chapter of the American Academy of Pediatrics(the “Chapter”), I recognize that I owe duties of care and loyalty to the Chapter.  I further understand that one aspect of fulfilling those duties requires me to avoid the influence of conflicting interests when making decisions on behalf of the Chapter.  I understand that a conflict of interest exists whenever my allegiance might be split between a Chapter position or responsibility and some other professional, business, or personal position or responsibility, regardless of whether I am compensated in either capacity.

On this form I am therefore disclosing other situations or areas in which it might even appear that I have duties to other persons or entities which conflict with my duties to the Chapter.  I invite any further review by the Chapter of any aspects of these situations or areas that might be considered appropriate.  Also, I will take such other steps as may be necessary or appropriate, as determined in the sole discretion of the Chapter’s Executive Board, to resolve any conflicts of interest that now or hereafter may affect my ability to make an independent and unbiased decision on behalf of the Chapter.

I understand that the resolution of a conflict of interest may require one or more of the following steps: (1) disclosure of the situation giving rise to the conflict of interest to those participating in and those affected by the decision; (2) abstention from participation in the deliberation of and voting on the matter in question; and/or (3) resignation of or withdrawal from my position with the Chapter.  If it is determined that any of those steps are necessary to protect against legal liability to the Chapter or to me arising from conflicts of interest, or if any of those steps are otherwise deemed by Executive Board to be in the best interests of the Chapter, I will abide by the directive of the Chapter’s Executive Board. 

A) The following are my professional, business, or personal positions, responsibilities or interests that might give rise to conflicts of interest with the Chapter:

B) The following are situations in which I am serving as a vendor, or which I am employed b y or consulting with vendor to the Chapter or its members:

I will update this disclosure if conflicts of interest arise in the future. *
I know of no current personal, professional or business position, responsibility or interest, including vendor situations, that might give rise to conflicts:
example: 334-954-2543 cell