Conflict of Interest Form, Board of Directors

Please answer each of the following questions.

(Please refer to the "Policy of Conflict of Interest and Disclosure of Certain Interests" for definitions)

Have you read the MRA "Policy of Conflict of Interest and Disclosure of Certain Interests" (the "Policy")?

Does there presently exist or has there existed at any time during the past three years a Contract or Transaction between MRA and yourself or a family member?

Does there presently exist or has there existed at any time during the past three years a Contract or Transaction between MRA and an entity in which you or a family member have a material financial interest or of which you or such family member is a director, officer, agent, partner, associate, trustee, or personal representative, receiver, guardian, custodian, conservator, or other legal representative?

During the past three years, have you accepted gifts, entertainment, or other favors under circumstances where it might be inferred that such action was intended to influence or possibly would influence you in the performance of your duties from any individual or entity that:

This does not preclude the acceptance of items of nominal or insignificant value or entertainment of nominal or insignificant value that are not related to any particular transaction or activity of MRA.

For the questions you answered "yes" to, please describe details below. Also please describe any other relationships, positions, transactions, or circumstances that you believe might constitute a potential conflict of interest as described in the Policy.

If more explanation is necessary, please contact Kathy Russ at kathyr@montreat.org

By selecting the checkbox labeled "Agreement" below, I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed and agree to abide by the "Policy of Conflict of Interest and Disclosure of Certain Interests" of MRA that is currently in effect.