2021-04-21 OMA Agenda - Board of Trustees

Since becoming a member of OMA, have you engaged in any activity that may have been a misrepresentation of your official position, title, or professional qualifications? If yes, state the particulars. _________________________________________________________________________________________________ If elected and seated as a member of the OMA Board of Trustees, how would you react to a board decision with which you personally strongly disagreed? _________________________________________________________________________________________________ Do you think you may have a potential conflict of interest or commercial involvement as outlined in the OMA Conflict of Interest Policy and Disclosure Statement that may prevent you or may be perceived by others as not allowing you to act solely in the best interest of the OMA while serving on the OMA Board of Trustees? If so, please provide a detailed overview on your disclosure form. _________________________________________________________________________________________________ All OMA Board of Trustee candidates are asked to provide OMA with the proper authorization for a standard criminal, professional and education background check. Will you consent to a standard background check? _________________________________________________________________________________________________

Signature: ____________________________________ Date: __________________

How and What to Submit: Return this fully completed application and the signed OMA Conflict of Interest Policy and Disclosure Statement (COI), along with any supplemental attachments, to OMA by June 2 1, 202 1. ( subject to approval by the BOT) Email: election@obesitymedicine.org Mail: 7173 S Havana St, Suite 600-150 Centennial, CO 80112 Fax: 303 - 779 - 4834 Only fully completed applications and COIs will be considered for review.