For purposes of this Disclosure, a “Vendor” is defined as any business or organization that you are or become aware of that (i) provides goods or services to, or does any other business with, the Academy or which has sought to do so within the past three years or which seeks to do so in the future or (ii) that competes with the Academy, its products or services, or the products or services of any affiliates. With respect to Academy and the Vendors:

I acknowledge that I have received a copy of the Conflict of Interest Policy (“Policy”) of the American 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 Annual Disclosure Information Form attached as Attachment 1. 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: • 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; • A compensation arrangement with the Academy or with any entity or individual with which the Academy has a Transaction; • A position in a public office or institution, whether appointed, elected or employed, which will require participation in matters involving the Academy; • A position as an uncompensated consultant, officer, Commission member or board member of any entity with which the Academy has a Transaction; or • 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). • I become aware that a member of my Family has a Personal or Private Interest.