Conflict/whistleblower Form

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2327 L Street, Sacramento, CA 95816
916.440.1985 • FAX 916.440.1986 • •
CONFLICT/WHISTLEBLOWER FORM
ANNUAL QUESTIONNAIRE
UNIT NAME _____________________
NAME: ________________________________________________________________
Telephone: (______) ______________
PTA POSITION: __________________________________________________________________________________________
Occupation:______________________________________________________________________________________________
Name of Employer: _______________________________________________________________________________________
Employer’s Address: ______________________________________________________________________________________
______________________________________________________________________________________
City
State
Zip
1.
I have read the California State PTA Conflict of Interest Policy (Section 2.3.2):
___ Initial
2.
I have read the California State PTA Whistleblower Policy (Section 2.3.10):
___ Initial
3.
I understand that as a board member, I have a responsibility to review the tax return: ___ Initial
4.
Are you currently being compensated by the PTA for services rendered to the organization (whether as a part-time or full-time
employee, independent contractor, consultant or otherwise) within the previous 12 months? ___Yes
___No
5.
Do you anticipate the receipt of compensation from the PTA for the rendering of services as described in question 1 above
during the upcoming 12 months? ___Yes
___No
6.
If any person bearing any of the following relationships to you is currently being compensated by the PTA for services rendered
to it as described in question 1 above within the previous 12 months, please list his or her name in the following space and
indicate the person’s relationship to you by using the relationships designated below (if no such person is being compensated,
please print the word “none” in the first space): ___Yes
___No
Relationships: brother, sister, ancestor, descendent, spouse, brother-in-law, sister-in-law, son-in-law, daughter-in-law, mother-in-law, father-in-law
Name _________________________________________
Relationship ___________________________________
7.
If any person bearing any relationship to you as described in question 3 above anticipates the receipt from the PTA for the
rendering of services to it as described in question 1 above within the next 12 months, please list his or her name in the
following space and indicate this person’s relationship to you (if no such person anticipates receipt of such compensation,
please print the word “none” in the first space).
Name _________________________________________
Relationship ___________________________________
8.
Are you a director, an officer, an employee or an owner in any business or entity which has done business within the previous
12 months with the California State PTA, or currently is, or is contemplating doing business with the corporation? ___Yes
___No
If yes, please explain type of business, type(s) of transaction(s), relationship:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Date: ___________________, 20___
Signature _____________________________________________
Type or print name ______________________________________
2010 California State PTA Service Mailing

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