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Conflict of Interest UWPC 2017

United Way of Porter County (6/2017)

 

UNITED WAY OF PORTER COUNTY

Conflict of Interest Disclosure Statement

United Way of Porter County’s Code of Ethics outlines the organization’s Conflict of Interest policies and should be closely reviewed by all Board and Committee members, other volunteers and staff.  It is understood that active volunteers may have other involvement in other areas.  As a result, these volunteers simply need to disclose and withdraw from discussion and voting on potential conflicts.  All known or potential conflicts should be disclosed below.

 

Conflict of Interest:  In order to avoid any future conflicts, please answer the following

questions.

                                                                                                                         

1.     Are you or any member of your immediate family a board                  YES           NO

member of a United Way of Porter County partner agency?

 

List agencies_______________________________________

 

2.     Have you or any member of your immediate family ever been             YES           NO

employed by a United Way partner agency?

 

List agencies_________________________Dates__________

 

3.     Do you or any member of your immediate family have a                      YES           NO

business interest as a supplier of goods or services to United

Way of Porter County or to a United Way partner agency?

 

List agencies_______________________________________

 

4.     Do you feel that you may have any situation that may appear             YES           NO

as a conflict of interest?

 

If you answered “yes” to any of the above questions, please give details in the space below.

 

________________________________________________________________________

 

________________________________________________________________________

 

 

I hereby affirm that, to the best of my knowledge, the information given above is complete and accurate.

 

SIGNATURE____________________________________ DATE__________________

 

PRINT NAME ___________________________________

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