CONFLICT OF INTEREST POLICY

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Name

First Name

Last Name

Date

MM

DD

YYYY

Email

Current position with Boys & Girls Clubs of North Central Georgia, Inc:

Corporate Board Director

Advisory Board Member

Current place of employment or principal business activity:

Currently held offices/directorships in for-profit and non-profit entities: (Organization name | Position | Date service began)

I will promptly advise the Chief Executive Officer of the Boys & Girls Clubs of North Central Georgia if I become affiliated with any additional organizations or if any of the affiliations described above are terminated or changed.

Yes

No

Signature

Please Type your full name and date of signing