ETHICS DISCLOSURE FORM FOR PROSPECTIVE SSA LEADERS & AWARDEES Company INSTRUCTIONS: PLEASE RETURN THIS FORM NO LATER THAN THE SPECIFIED REQUEST DATE. IF YOU HAVE QUESTIONS, CONTACT NAN BROADBENT, SSA EXECUTIVE DIRECTOR, AT NBROADBENT@SEISMOSOC.ORG . The Seismology Society of America (SSA) expects SSA leaders and awardees to embody high standards of scientific integrity, personal accountability and ethics in their professional activities as set forth in SSA’s Professional Ethics Policy. Pursuant to the Ethics Policy, SSA leaders include members of the Board of Directors and committees as well as Associate Editors. The Ethics Policy requires that all prospective SSA leaders and awardees complete this Ethics Disclosure Form to be considered for open positions or awards. Your Name & Contact Information First Name * Last Name * Affiliated Institution * Please type the full name of your institution. Mobile Phone * Email * Potential Positions or Honors State the SSA position for which you are being considered, if applicable: State the honor or award for which you are being considered, if applicable: Your Declarations 1. To the best of your knowledge, has a court, regulatory agency, employer, or other public or private entity issued a finding against you in which your professional conduct was at issue, including any instances of “Prohibited Conduct” as defined in Section E of SSA’s Professional Ethics Policy? has a court, regulatory agency, employer, or other public or private entity issued a finding against the nominee in which their professional conduct No Yes 2. To the best of your knowledge, are you currently under investigation by a court, regulatory agency, employer, or other public or private entity in which your professional conduct is at issue including any instances of “Prohibited Conduct” as defined in Section E of SSA’s Professional Ethics Policy? under investigation by a court, regulatory agency, employer, or other public or private entity in which their professional conduct No Yes Your Acknowledgement * By submitting this form, you certify that you have answered the above questions truthfully. SSA has the sole discretion to determine eligibility based on the disclosed information. Typically, individuals will be deemed ineligible if they fail to submit the Ethics Disclosure Form on time, or they disclose an adverse finding. When candidates disclose an ongoing investigation, SSA generally will deem the candidate temporarily ineligible for further consideration pending the outcome of the investigation. Date *
