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2023 Conflict of Interest Form
Conflict of Interest / Civic Involvement / Member Certification / Confidentiality
Conflict of Interest Policy
Any member of IMPACT 100 Pensacola Bay Area who serves as an employee or a board member for a nonprofit organization or who is personally involved with the nonprofit organization’s IMPACT 100 2023 Grant Application, shall not serve on the committee reviewing the nonprofit organization’s grant application, but is entitled to vote without restriction at the annual meeting. In addition, a member of IMPACT 100 Pensacola Bay Area serving on a committee who has a significant relationship with anyone involved with a nonprofit whose application is before the respective committee shall disclose the individual’s role with the nonprofit to the committee below, not participate in the site visit for that respective nonprofit, and follow the direction of the committee chair when the nonprofit’s grant application is being discussed.
Contact Information
Name
*
First Name
Last Name
Email
*
If you need to change your email, please type in the new email in the Comment Block at the end of this form.
Verify Email
*
Civic Involvement Disclosure (CHECK ALL THAT APPLY)
*
Do you and/or any significant relationship have affiliations with nonprofit organizations (e.g. staff, board member, business, volunteer)? Please list civic involvement and civic leadership positions in Escambia & Santa Rosa Counties held by you or your significant relationships. Committee chairs will contact you regarding any potential conflicts of interest. Check "None" if no personal or significant relationships civic involvement to disclose.
None
Personal (Yourself)
Significant Relationship (e.g. Family member)
My Disclosures
List any/all local organizations since the disclosures are reviewed for potential conflict of interests prior to reviewing grants applications.
My role in Organization 1:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Organization 1
Comments for Organization 1
Provide comments for amplifying information, if appropriate.
Organization 2
My role in Organization 2:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 2
Provide comments for amplifying information, if appropriate.
Organization 3
My role in Organization 3:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 3
Provide comments for amplifying information, if appropriate.
Organization 4
My role in Organization 4:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 4
Provide comments for amplifying information, if appropriate.
Organization 5
My role in Organization 5:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 5
Provide comments for amplifying information, if appropriate.
If you are involved with more than five organizations or have additional comments please list below:
Significant Relationship(s) Disclosures
List any/all local organizations since the disclosures are reviewed for potential conflict of interests prior to reviewing grants applications.
Organization 1.
Significant's role in Organization 1.:
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 1.
Provide comments for amplifying information, if appropriate.
Organization 2.
Significant's role in Organization 2.
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 2.
Provide comments for amplifying information, if appropriate.
Organization 3.
Significant's role in Organization 3.
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 3.
Provide comments for amplifying information, if appropriate.
Organization 4.
Significant's role in Organization 4.
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 4.
Provide comments for amplifying information, if appropriate.
Organization 5.
Significant's role in Organization 5.
Volunteer or Member
Board Member
Staff/Employee
Business Relationship
Comments for Organization 5.
Provide comments for amplifying information, if appropriate.
If more than five or additional comments for significant relationship disclosures, please list below:
Member Certification & Confidentiality
I hereby certify that I have read and agree to the Conflict of Interest Policy. I pledge to hold confidential all proceedings and discussions of IMPACT 100 Pensacola Bay Area Focus Area Committees.
Date
*
(mm/dd/yyyy)
Electronic Signature
*
First Name
Last Name
2023 Conflict of Interest Comments
If you will be unable to attend your committee's first meeting please notify your committee chair.
Click Submit to complete your submission.
