Conflict of Interest/Confidentiality Form

The Chatham Arts Council’s conflict of interest policy requires all board members and panel members to file a statement listing individuals and organizations with which they are significantly affiliated and which may apply for funding.

This disclosure does not prevent members from participating on the board or on panels. We do require that members recuse themselves from evaluative discussion and votes concerning organizations and individuals listed on this disclosure.

Name
First Last
Email
I have a financial and/or policy-making interest related to the following organizations and individuals:*

Please enter NONE if you have no relationships to disclose here. To add lines for multiple disclosures, please use the plus sign next the first entry.
Members of my immediate family and/or household have a financial and/or policy-making interest related to the following organizations and individuals:*

Please enter NONE if you have no relationships to disclose here. To add lines for multiple disclosures, please use the plus sign next the first entry.
Signature*
I confirm that I am disclosing all relationships in which I or my immediate family/household members have financial or policy-making interest that may relate to grant-making or other financial decisions by the CAC.
Confidentiality*
I agree to hold all discussions related to grant-making in confidence.
Date
MM slash DD slash YYYY