Committees – Funding Arts Network

FAN Screener Sign-Up & Conflict of Interest Form

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Full Name*

Preferred Phone #:*

Email Address*

A. Please list below all Miami-Dade performing or visual arts organizations (Conflicted Organizations) in which you serve as Executive Director, a Board member, paid staff or from whose grant you would benefit as an artist or a relative of an artist. Use additional pages if necessary.

Organization:

Position

Organization:

Position

Pursuant to our policy, you may not serve on the Screening Team that will review the Conflicted Organization’s application listed above. You may serve on any other Screening Team.

B. List all Miami-Dade performing and visual arts organizations (Conflicted Organizations) to which you contribute a gift of more than $2,500 in funds or in-kind services, or from which you or a relative receives remuneration for goods or services. Use additional pages if necessary.

Pursuant to our policy, you may serve on the Screening Team that will consider the grant application of the Conflicted Organization listed above but may not be the screener for that organization. If you contribute more than $2,500 in cash or in-kind services to the Conflicted Organization, you may participate in the team discussion of that application only if you first disclose your donation to the team.

C. List organizations in which you serve as a volunteer.

Pursuant to our policy, if you are a volunteer you may serve on the Screening Team that will consider the Conflicted Organization's grant application, but you may not review it for the team or participate in the discussion of that application.

D. To sign-up for a discipline that presents no conflict that would completely exclude you from participation based upon A and/or B above, please indicate your 1st and 2nd choices below. Feel free to sign up for a discipline you would like to explore or learn more about. We will make every effort to accommodate your choice.

DANCE

MUSIC

THEATER

VISUAL ARTS

Any place needed

Will this be your first time screening? Choose yes or no below:

I have listed all conflicts of interest that might prohibit my participation on a Screening Team.

Signature

Date

Name

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FAN Screener Sign-Up & Conflict of Interest Form

A. Please list below all Miami-Dade performing or visual arts organizations (Conflicted Organizations) in which you serve as Executive Director, a Board member, paid staff or from whose grant you would benefit as an artist or a relative of an artist. Use additional pages if necessary.

B. List all Miami-Dade performing and visual arts organizations (Conflicted Organizations) to which you contribute a gift of more than $2,500 in funds or in-kind services, or from which you or a relative receives remuneration for goods or services. Use additional pages if necessary.

C. List organizations in which you serve as a volunteer.

I have listed all conflicts of interest that might prohibit my participation on a Screening Team.

FUNDING ARTS NETWORK