Last modified on 3 June 2010, at 21:46

Conflict of Interest Questionnaire

Wikimedia Foundation

Conflict of Interest Questionnaire

Wikimedia Foundation (“WMF”) requires each board member, officer and key employee (as defined in the Form 990) annually:

1. to review the WMF's Conflict of Interest Policy (the “Policy”);
2. to disclose any possible personal, familial, or business relationship that reasonably could give rise to a conflict of interest or the appearance of a conflict of interest in the Conflict of Interest Questionnaire; and
3. to acknowledge by his or her signature that he or she is acting in accordance with the letter and spirit of such Policy on the Pledge of Personal Commitment.

The information provided on this form shall be available for inspection by members of the Board, the Executive Director, the Chief Financial Officer and WMF’s legal counsel, but shall otherwise be held in confidence except when, after consultation with the applicable signatory, the Board determines that WMF’s best interest would be served by disclosure.

Please respond to the following questions to the best of your knowledge.

1. Please list all corporations, partnerships, associations or other organizations of which you are an officer, director, trustee, partner, or employee, and describe your affiliation with such entity.

2. Please list all corporations, partnerships, or other entities in which you have a material financial interest as defined in the Policy as entities in which Covered Persons and all individuals or entities having significant relationships with the Covered Person own, in the aggregate, more than 10%. Please also list the actual ownership percentage.

3. Please list any existing and/or proposed business dealings between WMF and you, your family members, and/or entities. Describe each such relationship listed and the actual and potential financial benefits as you can best estimate them.

4. Are you aware of any other relationships, arrangements, transactions, or matters which could create a conflict of interest or the appearance of conflict? If so, please describe.

5. Please list all business dealings that you, your family members, and/or entities have had with WMF in the past two years.


I have read the WMF Conflict of interest policy. I am currently, and agree to remain, in compliance with the Policy.

Entered into on this the ______ day of _______, 20__.

___________________________
Member, Board of Trustees
Wikimedia Foundation, Inc.