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DocuSign Envelope ID:AA509FB2-A0C3-456C-9F67-9DDC0879C15B t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> I.) •ISCLOSURE OF POTENTIAL CO 'FLICTS OF INTEREST <br /> Are any of the Board Members or employees of the agency, which will be carrying out this project, <br /> or members of their immediate families, or their business associates: <br /> YES NO <br /> rj xn a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> El x[1] b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> El xi] c) Current beneficiaries of the project/program for which funds are requested? <br /> El xEl 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 1 y k lowledge ani belief all of the bove infor Ilati.n is true and <br /> current. I acknowledge an understand that the existence of a potential conflict of interest <br /> does not necessarily make the project ineligible for funding, is ut the existence of an <br /> undisclosed conflict may result in the termination of a y_grant awarded. <br /> , . <br /> Signature: 1A _ /I Ll /ixecutive 6- <br /> Director Date <br /> Signature O4/ - ;._A I 1 /2) '7__ /it, <br /> ;toard Chaiterson 1 , Date <br /> Main Application 1/26/2016 10:50:19 AM P ,), ,cj r.- 1 3 (-) t 1 9 <br />