Form Spi 1576 Sample Letter To Board Members, Managers, And Supervisors In Organizations Participating

Form Spi 1576 Sample Letter To Board Members, Managers, And Supervisors In Organizations Participating - Cacfp Page 3

Information to Gather From Principals

in Organizations Applying or Re-applying

to Participate in the

Child and Adult Care Food Program

During the past seven years, if you were employed as a supervisor or manager by any public

or private organization that participated in a publicly-funded program (any program funded

wholly or in part by federal, state, or local dollars), or if you were a member of a governing

board or similar body of any public or private organization that participated in a publicly-funded

program, please list the name of the organization, the name of the publicly-funded program,

your job title, and the years of your association with this organization/program:

Name of organization

Name of program

Job title

Years

employed

FOR EACH OF THE FOLLOWING CIRCLE ONE ANSWER:

• I have/have not been a principal in an organization participating in a publicly-funded

program that has been ruled ineligible as a result of violating that program’s

requirements during the past seven years.

• I have/have not been convicted of a business-related offense during the past seven

years.

• I am/am not on the Child and Adult Care Food Program’s (CACFP) National Disqualified

List.

• I was placed on the CACFP National Disqualified List on

(enter date)

PLEASE ANSWER THE FOLLOWING: if you hold any of the following positions in an

organization participating, or applying to participate, in the CACFP:

• The chairman of the board of a nonprofit institution; or

• The chairman of the governing board of a public or quasi-public entity; or

• The owner of a proprietary business; or

OSPI/Child Nutrition Services

FORM SPI 1576 (Rev. 8/05)

Page 3

Attachment 15 to Bulletin No. 043-12 CNS

September 25, 2012

Form Spi 1576 Sample Letter To Board Members, Managers, And Supervisors In Organizations Participating - Cacfp Page 3