If you are interested in volunteering for a review team, please fill out the conflict of interest form below. Teams are determined by December of each year. The Deadline for the coming year is December 31, 2016.

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1
Name
Address
City/State/Zip
Email
Home Phone
Work Phone
Place of Employment
Are you a member of a Board of Directors for any United Way agency (UWWV agencies identified in enclosure)?pick one!
If yes, which agency(ies)?
Is your spouse, or any immediate family member, a member of a Board of Directors for any United Way agency?
If Yes, which agency(ies)?
Are you, your spouse, or any immediate family member employed by any United Way agency?
If yes, which agency(ies)?
Is there any agency (other than those identified above) for which you believe you might have a conflict of interest in reviewing their program funding request?
If yes, which agency(ies)?
Your Concern
Have you ever participated in any United Way annual funding process?
If Yes, how many years have you participated and where?
Regarding your schedule, will you be able to commit to approximately five 2-hour meetings and several agency visits over a 6-week time period in January and early February?
Are you or your spouse (please type you or spouse or both) a contributor to the annual United Way of the Wabash Valley Campaign?
If No, would you be willing to contribute? (We ask that all UWWV review team members (or their spouse) make a donation of any amount to the UWWV Campaign as you are representing donor interests in determining where campaign donations are distributed.)
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