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DocuSign Envelope ID:636AFD33-DA5C-4B55-88DC-03C0863BAFE3 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br /> Are any of the Board Members or employees of the agency which will be carrying out this project, or <br /> members of their immediate families, or their business associates: <br /> YES NO <br /> El El a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> Z b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> El c) Current beneficiaries of the project/program for which funds are requested? <br /> 1-1 E3) 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 project ineligible for funding, but the existence of an <br /> undisclosed conflict ma result in the t-miination of any grant awarded. <br /> C3-7 <br /> Signature: - 2- ? <br /> Executive Direct;IL - Date <br /> Signature: A.,i66rt? , 1 1-..2 -4; <br /> Board Chairperson Date <br /> Main Application 1/20/2016 1:27:47 PM Page 16 of 2 :3 <br />