Orange County NC Website
Browse       Search
DocuSign Envelope ID: 112713E4-A11E-4CO3-B5A6-92020A894CD7 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 /> ❑ ® a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> ❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> ❑ ® c) Current beneficiaries of the project/program for which funds are 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 current. I <br /> acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the project inel'gible for funding, but the existence of an undisclosed <br /> conflict may result in the terminal,n of any grant awarded. <br /> Signature: / p � <br /> 1/25/16 <br /> Executive I rector Date <br /> 1/25/16 <br /> Signature: (91.44- aligir:(114-° <br /> Board Chairperson Date <br /> Main Application 2/1/2016 11:26:11 AM I:' c 12 of 1 <br />