CONFLICT OF INTEREST DISCLOSURE STATEMENT

As a speaker at the _______fill in name of event_________, I hereby disclose the following (check all that apply)

• The ___fill in name of Gulenist organization____ is paying me and/or my spouse an  (circle all that apply) honorarium / reimbursement / stipend / scholarship / gift / grant in the form of (circle all that apply) cash / check / electronic transfer in the amount of $__________.

• The ___fill in name of Gulenist organization____ is making a donation, or giving a grant to my organization/institution ___fill in name of your organization____ in the amount of $______________.

• The following individuals ________________________________________ of the ___fill in name of Gulenist organization____ made donations in the total amount of $__________ to my political campaign.

• I and/or my spouse was a participant at a Turkey trip organized by ___fill in name of Gulenist organization_____ on the dates of _______ through ________.  All expenses of this trip, valued at $____________, (circle one) excluding / including airfare were paid for me.

• I attended a conference on the Gulen Movement organized by ___fill in name of Gulenist organization____ in ________________ on the dates of __________, and received an honorarium in the amount of $____________ as well as meals, transportation and lodging valued at $____________.

• I attended a (circle all that apply) dialogue dinner / Noah’s pudding event / iftar dinner / Ramadan dinner / 9-11 memorial dinner / dinner honoring firemen and/or police organized by ___fill in name of Gulenist organization_______in ________________ on the dates of __________.

• I was the recipient of a gift from ___________________ of the ___fill in name of Gulenist organization___ in the form of a (circle all that apply) ceramic plate / plaque / tea set / other (please specify___________).

• I was the recipient of an award from the __fill in name of Gulenist organization___ entitled __________________ at the ______________event on ______________.

Note: For a list of Gulenist organizations, see http://turkishinvitations.weebly.com/gulenist-non-profits.html

I hereby further disclose that:
The following individuals _______________________________________of the ___fill in name of Gulenist organization_____ met with me on _________________________.  Subsequent to this/these meeting(s), I (circle one) have / have not made an attempt to perform my own independent background research to verify the veracity of any claims made by these individuals regarding Fethullah Gulen, the Gulen Movement, Turkey’s state of democracy, judicial independence and media freedom, and/or the “Ergenekon” and “Sledgehammer” investigations.

In preparing the content of my talk I (circle one) was / was not influenced by discussions with the following individuals ____________________________________ of the ___fill in name of Gulenist organization_____.

I hereby certify that the information disclosed herein is, to the best of my knowledge, complete and accurate. 

Name:________________________________

Signature:_____________________________

Date:_________________________________