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8 <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br /> Are any of the Board Members or employees of the agency which will be carrying out this program <br /> or members of their immediate families, or their business associates... <br /> YES NO <br /> ❑ ❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> ❑ ❑ b) Members of or closely related to members of the governing bodies of the Town of <br /> Carrboro, the Town of Chapel Hill, or Orange County? <br /> ❑ ❑ c) Current beneficiaries of the program for which funds are being requested? <br /> ❑ ❑ d) Paid providers of goods or services to the program or having other financial interest in <br /> the program? <br /> If you have answered YES to any question, please provide a full explanation below. <br /> To the best of my knowledge and belief all of the above information is true and <br /> current. I acknowledge and understand that the existence of a potential conflict of interest <br /> does not necessarily make the program ineligible for funding, but the existence of an <br /> undisclosed conflict may result in the termination of any grant awarded. <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> Board Chairperson Date <br /> AGENCY INFORMATION Page 7 of 17 <br />