Kumamoto University
Conflict of Interest Disclosure Statement (Part )
Ⅰ
Please submit this statement only if any of the following items 1-5 applies.
1
During the period of January 1, 2017 to the present, have you held 5 percent or more of listed stocks of any partner company of industry-academia-government collaboration?
□ Yes □ No
2
During the period of January 1, 2017 to the present, have you held unlisted stocks (including stock options) of any partner company of industry-academia-government collaboration?
□ Yes □ No
3
During the period of January 1, 2017 to December 31, 2017, have you received any royalty from a partner of industry-academia-government collaboration, or are you planning to receive it in the future?
□ Yes □ No
4
During the period of January 1, 2017 to December 31, 2017, have you received 1,000,000 yen or more as compensation from a side job from a single company (or corporation or organization), or are you planning to receive it in the future?
□ Yes □ No
5
*(If your answer to any of the above questions is yes, please answer the following question. ) During the period of January 1, 2017 to December 31, 2017, have you been involved in purchasing any equipment or products, and/or receiving any services from the company (or corporation or organization) corresponds to any of the above questions 1 to 4, or are you planning to receive it in the future?
□ Yes □ No
Date of Submission: 2018(Y)/ (M)/ (D)
Personal Number
(Please fill in your personal number and date of submission.)
Deadline for Submission: Friday, April 27, 2018
Please submit the Disclosure Statement and direct any inquiries to: External Affairs Department Social-Academic Collaboration Division
