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. <br />~~1~IT"~,R • A~~~~~"T~~PAl;~~,,,, ~yi T~W0 <br />Part C. Evidence of Nonprofit Organization <br />SECTION 2. LIST OF THE NONPROFIT ORGANIZATION'S BOARD MEMBERS, DIRECTORS AND OFFICERS <br />Name: Title: <br />Home Address: <br />City: <br />Occupation: <br />St.: Zip: Phone: ( ) Ext: <br />Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity?~OE]Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? Yes ❑ No <br />Name: Title: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes El No <br />(2) have a relationship, as Affiliate or othervuise, wl members of the Applicant or Development Team? M Yes ❑ No. <br />Name: Title: <br />Home Address: <br />City: St.: Zip: Phone: ( ) Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? Yes ❑ No <br />Name: <br />Home Address: <br />City: <br />Occupation: <br />Ext: <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? ❑ Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? ❑ Yes ❑ No <br />Name: <br />Home Address: <br />City: <br />Title: <br />Title: <br />St.: Zip: Phone: <br />Ext: <br />Occupation: Fax: ( ) <br />Does the individual (check all that apply): (1) serve as a private individual acting in a private capacity? El Yes ❑ No <br />(2) have a relationship, as Affiliate or otherwise, w/ members of the Applicant or Development Team? 0 Yes ❑ No <br />(Make additional copies of this form as required for additional board members, directors, and officers.) <br />St.: Zip: Phone: <br />Fax: <br />10 An individual is considered to be acting in a private capacity if the individual is not an employee of a public body and <br />is not being paid by a public body while performing functions in connection wifh the nonprofit organization. A public <br />body is any state, cify, county, town, township, village or other general purpose political subdivision of the state. <br />11 If "Yes", attach explanation of such relationship to this form. <br />Part II, Page 15 of 15 <br />