SECTION VI. Certification:
Please review your information for accuracy, print the form, sign it, and either email a scanned pdf to
lskelto@siue.edu, fax it to 618-650-3523 or mail it to Linda Skelton, Campus Box 1046, Edwardsville, IL
62026-1046.
By signing this form, I certify that I have read the Southern Illinois University Edwardsville Conflict of Interest
and Commitment Policy 1Q9 (http://www.siue.edu/policies/1q9.shtml) and agree to those terms listed in the
policy. I further certify this disclosure is true and complete to the best of my knowledge. I understand and
agree that it is my responsibility to update my disclosure annually or within 30 days of discovering or acquiring
a new SFI (e.g., through purchase, travel, marriage, or inheritance).
I understand that, if I have any SFI, members of the FCOI Committee are required to review my disclosure for
FCOIs. Every FCOI Committee member has signed a confidentiality agreement.
Investigator Signature
Date
SIUE FCOI Chair Signature (or designee signature)
Date
Form Revised 06/26/2013
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