Professional Conduct Disclosure

USITT PROFESSIONAL CONDUCT DISCLOSURE FORM

As a candidate for a United States Institute for Theatre Technology (USITT) award, honor, or governance position, please complete this online Professional Conduct Disclosure Form no later than the specified request date. If you have questions, you may contact the USITT Ethics Office using this link.

Have you been subject of a filed allegation, complaint, investigation, sanction or other legal, civil or institutional proceeding, where there was a finding of misconduct; or, are you currently the subject of such an allegation, complaint, or investigation in which your professional conduct is at issue?

Yes

No

If yes, you will be contacted for a confidential discussion of the details of the complaint.

CERTIFICATION

The undersigned hereby affirms that he/she has read, understands, and agrees to comply with the USITT Ethics Policy, including its Code of Conduct, and other policies and procedures established by USITT, as amended from time to time. By signing this document, I certify that, to the best of my knowledge, the above response and all information provided by me related to this Professional Conduct Disclosure Form are truthful, accurate, and complete, and I agree to notify USITT promptly of any material changes required in my responses to the above question. I acknowledge that failure to comply with USTT’s Ethics Policy, including its Code of Conduct, may result in my ineligibility to receive, or revocation of, any USITT award, honor, other type of USITT recognition, or governance position, and is grounds for potential sanctions against me.

Electronic Signature

Please sign in the box above using your mouse, stylus, or finger, depending on your device.

Name

Email

Phone

Date

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Developed from the American Geophysical Union’s (AGU) Self Disclosure form.