2026 Disclosure of Conflicts of Interest Form

2026 Disclosure of Conflicts of Interest Form

CCWN Governance Policies and Procedures - Policy 506
I,
Board Member Name:

First NameLast Name
acknowledge having received and read a copy of Community Care of West Niagara's Conflict of Interest Policy for Members of the Board of Directors.
Please list below any potential conflicts of interest you may have in relation to your role as a Director of Community Care of West Niagara. Please include in this list the following:
1. Any organizations (other non-profits/charities, funders, businesses) in which you, or an immediate family member participates in, that has, or may have, a relationship with or be in competition or perceived competition with Community Care of West Niagara.
2. Any other potential conflicts of interest of which you are aware.
Board Member Name:

First NameLast Name
Board Member Signature:
Date

MonthDayYear
Date
Should be Empty:

I,