Page 50 - IACET Application

I5O=Idea. Information. Insight. Implementation. Intervention. Outcome.
i5o Consulting Services

1.7 - Disclosure of Proprietary Interests

Conflict of Interest

Date:

Name:
Email Address:

I certify that I have read and know the I5O’s conflict of interest policy and that the foregoing information is true
and complete to the best of my knowledge.

All instructors providing services under the authority of this certification course/program are required to
disclose any interest they have in any products, instruments, devices or materials that may be
included in their training.
Any such disclosure must be in writing and must specify the nature of the interest. Further, disclosure
of the interest must be included in any promotional material and communications for the learning
event.

Name (please print)

Signature, Date