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2020 Director Information Sheet

I have read the Davidson County Community College Foundation, Inc.’s Conflict of Interest Policy and agree to comply fully with its terms and conditions at all times during my service as an officer, director, volunteer, or key employee of DCCC Foundation, Inc. If I become aware of any actual or potential conflicts of interest at any time following the submission of this form, or if the information provided below becomes inaccurate or incomplete, I will promptly notify DCCC Foundation, Inc., or the Executive Director or President of DCCC Foundation, Inc.

Contact Information
Name (as you want it listed in official publications)*
Preference for Name Tag:*
Spouse/Significant Other Name:
Employer (please note if retired):
Job Title:
Preferred Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code
Preferred Phone*
Preferred Email*
Are you willing to receive all Foundation correspondence electronically?*
- Yes
- No
Acknowledgment and Disclosure Form
I have read the Davidson-Davie Community College Foundation, Inc.'s Conflict of Interest Policy and agree to comply fully with its terms and conditions at all times during my service as an officer, director, volunteer, or key employee of Davidson-Davie Community College Foundation, Inc. If I become aware of any actual or potential conflicts of interest at any time following the submission of this form, or if the information provided below becomes inaccurate or incomplete, I will promptly notify Davidson-Davie Community College Foundation, Inc., or the Executive Director or President of Davidson-Davie Community College Foundation, Inc. Disclosure of actual or potential conflicts of interest:
Do you receive compensation as an officer, director, committee member, task-force member, or key employee of Davidson-Davie Community College Foundation, Inc.?*
- Yes
- No
Other than reimbursement of reasonable expenses, have you received or do you expect to receive more than $10,000 per year from Davidson-Davie Community College Foundation, Inc. in addition or apart from the benefits described in the above inquires?*
- Yes
- No
Does any family member receive compensation or material financial benefit from Davidson-Davie Community College Foundation, Inc.?*
- Yes
- No
Do you have a family relationship or business relationship with any current or former officer, director, or key employee of Davidson-Davie Community College Foundation, Inc.?*
- Yes
- No
If you answered "Yes" to any of the above, please explain in a separate statement:
Board Member Signature:*

By typing your name here it is considered to be your signature on this document.

OUR DEDICATION. YOUR JOURNEY.

Foundation@davidsondavie.edu

Mailing Address: PO Box 1287 · Lexington, NC 27293
Davidson Campus Physical Address: 297 DCC Road, Thomasville, NC 27360, 336.249.8186
Davie Campus Physical Address: 1205 Salisbury Road, Mocksville, NC 27028

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Lexington, NC 27293

336.224.4680

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