2013 PVO Standards Compliance Certification Form for New Members

On

behalf

of_________________________________________________(enter

your

organization’s name), I have reviewed the InterAction PVO Standards and hereby certify that we are in compliance in all areas, except as noted below (attach additional sheets if necessary). Where we are not presently in compliance, the reasons for non-compliance, and any steps we plan to take, are also briefly described. I acknowledge that this form satisfies our compliance with the PVO Standards for the calendar year in which we are joining the InterAction membership. I understand that for the next PVO Standards Compliance year (2014), we will be required to complete Self-Certification Plus to maintain our compliance with the PVO Standards and membership with InterAction. Standard Description

I would like a representative from InterAction’s Membership and Standards office to contact me for assistance. (Please enter preferred contact information.) Email: Telephone:

CERTIFIED BY: President/Chief Executive Officer: OR Chair, Board of Directors: Date: Date: