Workforce Innovation and Opportunity Act
Conflict of Interest Policy Attestation

Please review the LWP Conflict of Interest Policy before completing this form. All required questions must be completed.

I do hereby attest and affirm that I have received, read, and understand the Lane Workforce Partnership (LWP) Conflict of Interest Policy and agree to be bound by it. I will promptly inform the LWP Board Chair of any material change that develops in the information contained herein.

Question Title

1. I am a (select all that apply): (Required.)

Prospective Board Member

Current Board Member

Council Member of Lane Workforce Council

Committee/Task Force Member of Lane Workforce Partnership

Question Title

2. Select ONE of the two options below: (Required.)

I have a conflict to disclose. Conflict can include the following: (1) I represent a private sector employer that has current business/contractual dealings with LWP or one or more of the WIOA or federally funded service providers; (2) I have a family member who is employed by a current or potential WIOA or federally funded service provider or by another organization that provides services direction to LWP; (3) I represent a WIOA-funded service provider/contractor; (4) I represent a One-Stop Operator; (5) I represent a One-Stop Partner.

I do not have a conflict as listed above to disclose. If any of the above reasons for a conflict arise, I will immediately inform the LWP Board Chair of a conflict of interest.

Question Title

3. If you answered "I have a conflict to disclose", please briefly describe the potential conflict including the organization or individual involved and the nature of the relationship.

I understand that if I have a conflict of interest related to a matter before the Board, I will disclose the nature and extent of the conflict before discussion or voting occurs. I will not participate in the discussion or vote on the matter, except that I may respond to direct questions from other LWP Board Members.

Workforce Innovation and Opportunity Act
Conflict of Interest Policy Attestation

Question Title

1. I am a (select all that apply): (Required.)

Question Title

2. Select ONE of the two options below: (Required.)

Question Title

3. If you answered "I have a conflict to disclose", please briefly describe the potential conflict including the organization or individual involved and the nature of the relationship.

Question Title

4. Name (Required.)

Question Title

5. Organization and Title (Required.)

Question Title

6. Date (Required.)

Workforce Innovation and Opportunity Act Conflict of Interest Policy Attestation

Question Title

* 1. I am a (select all that apply): (Required.)

Question Title

* 2. Select ONE of the two options below: (Required.)

Question Title

* 3. If you answered "I have a conflict to disclose", please briefly describe the potential conflict including the organization or individual involved and the nature of the relationship.

Question Title

* 4. Name (Required.)

Question Title

* 5. Organization and Title (Required.)

Question Title

* 6. Date (Required.)

Workforce Innovation and Opportunity Act
Conflict of Interest Policy Attestation

1. I am a (select all that apply): (Required.)

2. Select ONE of the two options below: (Required.)

3. If you answered "I have a conflict to disclose", please briefly describe the potential conflict including the organization or individual involved and the nature of the relationship.

4. Name (Required.)

5. Organization and Title (Required.)

6. Date (Required.)