By checking, I certify that neither I nor a family member, except as described below, is not now nor at anytime during the past year been:

a. A participant, directly or indirectly, in any arrangement, agreement, investment, or other activity with any vendor, supplier, or other party doing business with the Michigan Beer and Wine Wholesalers Association, or any of its wholly-owned subsidiaries, which has resulted or could result in personal benefit to me or my family members.

b. A recipient, directly or indirectly, of any salary payments or loans or gifts of any kind or any free service or discounts or other fees from or on behalf of any person or organization engaged in any transaction with the Michigan Beer and Wine Wholesalers Association, or any of its wholly-owned subsidiaries.

By checking, I certify that I have read the Michigan Beer & Wine Wholesalers Association Conflict of Interest Policy and agree to comply with said policy. I further certify that the above information is accurate and complete to the best of my knowledge and agree to amend this Conflict of Interest Disclosure Form in the event the disclosed information changes and is no longer accurate.