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Program Funding Review Process Conflict of Interest Form Panel Member
PLEASE APPLY BY: NOVEMBER 15
*Denotes required field |
TODAY'S DATE : |
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*NAME: |
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*ADDRESS FOR YOUR MAIL: |
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*CITY/STATE/ZIP : |
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*CONTACT PHONE : |
Please use (xxx-xxx-xxxx) format. |
*MY CONTACT PHONE IS MY : |
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PLACE OF EMPLOYMENT: |
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E-MAIL ADDRESS: |
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*If "Yes," which agency(ies)?
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*2. Is your spouse, or any immediate family member,
a
member of a Board of Directors for any United Way agency? |
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*If "Yes," which agency(ies)? |
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*3. Are you, your spouse, or any immediate family
member
employed by any United Way agency? |
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*If "Yes," which agency(ies)? |
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*4. Is there any agency (other than those identified
above)
for which you believe you might have a conflict of interest in
reviewing their program funding request? |
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*If "Yes," which agency(ies)?
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*Your concern: |
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5. Have you ever participated in any United
Way
annual fund distribution process? |
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If "Yes," how many years have you participated and where? |
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6. Regarding your schedule, what days and times
during the week are good for meetings? |
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*7. Are you a contributor to the annual
United
Way of the Wabash Valley Campaign? |
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*If "No," would you be willing to contribute? |
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8. Other comments? |
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