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~~ <br />SAMPLE <br />ATTACHMENT D <br />AGREEMENT AND CERTIFICATION <br />Authorized officials of the organization MUST complete and sign the following statements. <br />Certification: This grant application has been approved by the lead applicant organization's governing body. <br />Certifreation: The lead applicant is either (select only one): <br />^ (I) anon-profit corporation which has as a significant purpose promoting the public's health, <br />or <br />® (2) a State or local government agency. <br />Certification: This organization has no conflicts of interest as defined by the policy below. <br />To avoid any real conflict of interest or perceived conflict of interest between the Health and Wellness Trust <br />Fund Commission grant recipients and tobacco manufacturing and related entities, grant recipients must not <br />currently accept any grants or anything of value from any tobacco manufacturer, distributor, or other tobacco- <br />related entities The only exception is when dtese grant funds or items of value are totally for NON-tobacco <br />related purposes and do not present any danger of promotion of or use of tobacco products or otherwise <br />conflict with policies and programs known to prevent and reduce teen tobacco use. <br />Agreenteat: All sub-recipients (includes partners, collaborators and other contractors) under the grant will be <br />identified on an ongoing basis. <br />Agreentettt: All accounts, books, ledgers and records for the grant project can be audited/reviewed by the <br />Commission, Commission staff, an outside auditor hired by the Commission and the State auditor. <br />Agreement: The Commission or Commission staff may make site visits at the Commission's convenience. <br />Agreentettt: Applicant will provide computer with minimal capabilities listed in the Application to provide <br />data, facilitate communication, and support of the management team. <br />Applicant Organization Fiscal Year (Month/Day through Month/Day): <br />Julyl, 2006 through Jmie 30.2007 <br />CERTIFICATION: The information provided in this material is correct and complete, (Note: Must be <br />signed by the chair of the Board of Directors or head of lead applicant organization.) <br />Applicant Organization: Oran>?e County Health Depaztment <br />Signatuae: Signature: <br />Title: Health Director Title: <br />Date: Date: <br />Chair. Board of Health <br />Organization's Federal Employer Identification Number: 56-6000327 <br />30 <br />