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DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 11 Counselors in <br /> Training 2 100% 0 0 0 0.00% <br /> Notes: <br /> • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line <br /> item. <br /> • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. <br /> • + Denotes the percentage of staff time involved with this program. <br /> • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: <br /> Total Volunteer Hours = Volunteer FTE <br /> 1,960 <br /> DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br /> Are any of the Board Members or employees of the agency which will be carrying out this <br /> project, 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 Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? NO <br /> b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? NO <br /> c) Current beneficiaries of the project/program for which funds are requested? NO <br /> d) Paid providers of goods or services to the program or having other financial interest in <br /> the program? NO <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 <br /> interest does not necessarily make the project ineligible for funding, but the existence of <br /> an undisclosed conflict may result in the termination of any grant awarded. <br /> Signature: 1/25/2016 <br /> Executive Director Date <br /> Signature: 1/25/2016 <br /> Board Chairperson Date <br /> 0:°P . 14 of 23 <br />