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� . <br /> DocuSign Envelope ID:24839407 oe2D-47A2 e388-3eEA00100uC1 i /\ - 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 p ject, or <br /> members of their immediate families, or their business associates: <br /> YES NO <br /> El a a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrbono' orHillsborough? <br /> T b) Members of or closely related to members of the governing bodies of Chapel Hi|\, <br /> Carrboro, Hillsborough, or Orange County? <br /> [| u\ Current beneficiaries of the project/program forvvhichfundsorenaqueeted? <br /> E 'sr 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 may result in the termination of any grant awarded. <br /> /�� ) ' 2--( / (' <br /> Signature: // /«, �` ^ / ' <br /> Executive Director Date <br /> Signature: 000 <br /> 'Board Chairperson Date <br /> Main Application 1/20/2016 11:21:36 AM P e I 2 0f 2 � <br />