CONFLICT OF INTEREST DECLARATION FOR MITACS PROGRAMS
Note: Please discuss any potential Conflict of Interest with a Mitacs staff member
before you submit the proposal.
Mitacs program being applied for: Please select
Project Title:
Submission Lead: Please select
Name of declarant:
Please indicate if you are:
☐ Intern/Fellow
☐ Academic Supervisor:
University:
Organization Name:
Organization website:
Organization ownership
1. Please specify the percentage (%) of your ownership of the above-mentioned organization.
2. What is your position and responsibilities in that organization?
3. Please describe any involvement you have in the operation or management of the
organization.
Other Investors
4. What other investors are there in the above mentioned organization? Please list them:
Name
1.
2.
3.
…..
% of shares
5. Are relative(s) owners of the organization? If yes,
a. Specify the percentage (%) of their ownership
b. State your relationship to them (e.g. spouse, sibling, children, parent, other)
c. Describe their position and responsibilities in the organization
Organization Facilities
6.
Please indicate if the organization's R&D facilities are located:
a. Off -campus
b. On-campus in a different building from the professor’s lab/office
c. On-campus in the same building as the professor’s lab/office
7. Please provide the mailing address of the organization's R&D facilities:
☐
☐
☐
Organization Supervisor
8. Who will be the intern’s supervisor at the partner organization? Please provide the name,
contact information, and details of this individual’s position.
Organization Scientific Director
9. Does the organization any have an independent Scientific/Research Director? If yes, please
provide the name, contact information of this individual.
Research and Development Professional Staff
10. Does the organization employ its own professional R&D staff that will apply the research
results into the organization operations? Please provide details.
Management Team
11. Is the organization under the effective day-to-day management control of someone other
than the academic supervisor or Intern? If so, please provide their positions and
responsibilities.
Board of Directors
12. Does the organization have a Board of Directors with external members (i.e., some of
whose members, including the Chair of the Board, are at arm's length)?
University Policy Compliance
13. Does the commercial activity conform to the university's established policies relating to the
disclosure of commercial interest and conflict of interest?
14. Is the university aware of this possible conflict and prepared to ensure that the academic
interests of students and postdoctoral fellows are protected?
Please include any
documentation from the university confirming this.
______________________________
SIGNATURE
Return this form to the corresponding program:
Accelerate: accelerate@mitacs.ca
Elevate: elevate@mitacs.ca
Globalink: international@mitacs.ca
Converge: converge@mitacs.ca
_______________________
DATE