UC Conflict Waiver Intake Form

UC Conflict Waiver Intake Form

I understand and acknowledge my professional responsibility to disclose conflicts of interest, pursuant to California Rules of Professional Conduct, Rule 1.7. I confirm that I have fully complied with this rule, and representation in this matter is permitted.*

I’m authorized on behalf of my firm to enter into, execute and deliver this agreement and agree that any resulting conflict waiver will be a legally valid and binding obligation of the firm. I confirm that all of the information provided below is true, complete, and accurate.*

Name of Law Firm*

Name of Person Submitting Conflict Waiver Form*

Name of Attorney Responsible for Matter*

Email Address (Person Submitting Form)*

If you have more than one email address to enter, please separate the addresses with a comma followed by a space. Example: Email1@email.com, Email2@email.com

Phone Number (Person Submitting Form)*

Name of client(s) your firm proposes to represent.*

Insert name of client with potential adverse relationship to UC.

Legal Practice Area*

Select relevant practice area for the matter that is the basis of this request. If you have questions about which practice area your matter falls under, please contact UCLConflictWaivers@ucop.edu.

Select

UC Location(s) involved in proposed business*

Select or enter value

Nature of Potential Conflict (including your firm’s role with details re: nature of representation (i.e. clinical trials, contracts, agreements); how it relates to UC; UC contact)*

Conflict Waiver Acknowledgements

There is an ethical wall in place between attorneys with access to UC confidential information and those who in the future will be working on matters adverse to UC.*

Agree

Disagree

Please provide a rationale for requesting an exception to this requirement.*

Your firm currently, or has in the past five years, represents/represented UC or is/were adverse to UC (not including patent prosecution).*

Agree

Disagree

Previously Worked Practice Areas*

Please select all of the different practice areas you have worked in for the UC in the last five years. If you have questions about which practice area your matter falls under, please contact UCLConflictWaivers@ucop.edu.

Select or enter value

File Upload*

Please attach a list of all matters (if there are any, and not including patent prosecution) where your firm represents or represented UC or is/were adverse to UC within the past five years as well as any matters which resulted in litigation in the past ten years. Include all matter numbers and the names of any UC contacts for those matters.

Drag and drop files here or

Confirmation*

I confirm there is no subject matter overlap between this matter on the one hand, and any of the matters described on the attached list on the other.

Yes

Please explain below why you believe the conflict can nonetheless be waived.

I acknowledge that if a waiver is granted, it does not permit my firm to accept representation that is adverse to UC for a matter that is substantially related to work done for UC.*

Agree

Disagree

Please provide a rationale for requesting an exception to this requirement.*

I certify that my firm will not enter into litigation adverse to UC.*

Confirm

Do Not Confirm

Please provide a rationale for requesting an exception to this requirement.*

I acknowledge that if a waiver is granted for this request, it CANNOT be considered as an advance waiver of potential future conflicts.*

Confirm

Do Not Confirm

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.