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CONFIDENTIAL QUESTIONNAIREDATE COMPLETED: CLIENT NAME (1): DOB / / CLIENT NAME (2): DOB / / HOME ADDRESS: CITY, STATE, ZIP: HOME PHONE: CLIENT (1) Preferred Name: CELL PHONE: WORK PHONE: EMAIL ADDRESS:

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The purpose of confidential questionnaire - balanced is to promote transparency and integrity by identifying and managing potential conflicts of interest.

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Financial interests, gifts, and other potential conflicts of interest must be reported on confidential questionnaire - balanced.

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