Conflict of Interest Policy

Name of person completing this form(Required)

1. Do you serve on the governing body of another organization? Answer yes if you are a director, trustee, or officer of another organization, including both taxable and tax-exempt.(Required)

Yes

Third Choice

If yes, please list:

2. Were you or are you an employee of the Buck Institute?(Required)

Yes

N/A

If yes, did you receive benefits or other compensation that were above the salary and benefits authorized by the Board or your supervisor?

Yes

N/A

3. Did you receive compensation or other payments from the Buck Institute as an independent contractor?(Required)

Yes

If yes, please list:

4. Were you or any Family Member involved in a transaction with the Buck Institute?(Required)

Yes

If yes, please list:

5. Did you have a Family Relationship or Business Relationship with any other Trustees, Officers, or Key Employees of the Buck Institute?(Required)

Yes

If yes, please list:

6. Did you or a Related Person receive a grant, gift or other assistance provided by the Buck Institute?(Required)

Yes

If yes, please list:

7. Were you, or an Interested Person with which you are affiliated, involved in a Business Transaction with the Buck Institute for which payments were made during the Certification Period?(Required)

Yes

If yes, please list:

8. Were you, or an Interested Person with which you are affiliated, a party to a loan with the Buck Institute that was outstanding?(Required)

Yes

If yes, please list:

CERTIFICATION.

I answered NO to questions 2 through 8 and I am not aware of any financial interest involving me or a Family Member that could present a conflict of interest.

I answered YES to one or more questions in 2 through 8.

I am a Trustee. I have discussed my responses with the Chair of the Board or the President. The transaction was or will be reviewed and approved by the Executive Committee or the Board of Directors.

I am not a Trustee. The President has informed me that the transaction either does not present a conflict of interest or that the Executive Committee or the Board has reviewed and approved the transaction.

Are you aware of any current or proposed Covered Transactions (as defined in the Policy) or any other transactions between the Corporation and you, a Family Member, or an Affiliated Entity (each as defined in the Policy)? If so, please describe.(Required)

Are you aware of any other relationships, arrangements, transactions or matters involving the Corporation which could create a conflict of interest or the appearance of a conflict? If you are aware of any of the above, please describe.(Required)

Please list your Affiliated Entities (including entities affiliated through a Family Member), and any other entities in which you have an economic interest, that by their nature or purposes might seek to enter into a transaction with the Corporation.(Required)

I have received and read the Corporation’s Conflict of Interest Policy. I am currently, and agree to remain, in compliance with the Policy. The information I provided above is true and correct as of the date of my signature.

Consent

I agree to the privacy policy.

Name(Required)

First Last

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Date(Required)

MM slash DD slash YYYY

Current Employer(Required)

Title(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred telephone contact number(Required)

Preferred e-mail contact address(Required)

I agree to the privacy policy.(Required)

I am a Trustee, Officer, Key Employee, or Employee of the Buck Institute. I have read and understand the foregoing policy applies to me.

I am Trustee of the Buck Institute and I understand that Sections 3.11 (Standard of Care), 7.03 (Self-Dealing Transactions), and 7.05 (transactions with organizations with common directors or trustees) of the Bylaws also apply to me.

Trustees Only: Do you consent to electronic transmissions to and from the Buck Institute at the e-mail address show above?

Yes

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Science is showing that while chronological aging is inevitable, biological aging is malleable. There's a part of it that you can fight, and we are getting closer and closer to winning that fight.

Eric Verdin, MD, Buck Institute President and CEO

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Conflict of Interest Policy

Keep up with our research.

Science is showing that while chronological aging is inevitable, biological aging is malleable. There's a part of it that you can fight, and we are getting closer and closer to winning that fight.

Support the Buck

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