SECTION 5: LEGAL ACTIONS Please list all pending and threatened litigation, arbitrations, or administrative proceedings to which you are a party or by which your assets or operations may be affected. Enter "none" if applicable. [ ] [ ] Does your organization carry Directors & Officers Insurance? YES NO SECTION 6: DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Do you or do your directors, officers, members, owners, or key employees have a personal, financial, employment, or other relationship with PTSSD or any of its directors, officers, or [ ] [ ] employees? YES NO If yes, please describe: SECTION 7: SIGNATURE OF OFFICER This Grant Request has been made with knowledge and permission by the Chief organization’s Officer. PLEASE PRINT ORGANIZATION: OFFICER: TITLE: DATE: SIGNED:
SECTION 5: LEGAL ACTIONS Please list all pending and threatened litigation, arbitrations, or administrative proceedings to which you are a party or by which your assets or operations may be affected. Enter "none" if applicable. Does your organization carry Directors & Officers Insurance? [ ] YES [ ] NO SECTION 6: DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Do you or do your directors, officers, members, owners, or key employees have a personal, financial, employment, or other relationship with PTSSD or any of its directors, officers, or employees? [ ] YES [ ] NO If yes, please describe: SECTION 7: SIGNATURE OF OFFICER This Grant Request has been made with knowledge and permission by the organization’s Chief Officer. PLEASE PRINT ORGANIZATION: OFFICER: TITLE: DATE: SIGNED:
GrantRequest-2016-GR.docx