NORTH CENTRAL WV COMMUNITY ACTION ASSOC., INC

CONFLICT OF INTEREST INFORMATION FORM

Name:       Date:  

County/Region:   (List your county if you are a staff person or list your region if you are a Board Member)

Affiliation to the Agency:

Please describe below any relationships, positions or circumstances in which you are involved that you believe could contribute to a Conflict of Interest, as defined by the North Central WV Community Action Assoc., Inc. Procedure on Conflicts of Interest.

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I hereby certify that the information set forth above is true and complete to the best of my knowledge.  I have read, understand and agree to abide by the North Central WV Community Action Assoc., Inc. Conflict of Interest Procedure.  I further agree to report any possible conflicts as they might arise apart from this annual report.