Orange County NC Website
Browse       Search
DocuSign Envelope ID:6BDD2794-5ECO-4DFF-B4F6-F496A1C3AB13 i /\ - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <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 /> x a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> Fl x b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> x Current beneficiaries of the project/program for which funds are requested? <br /> . | x d) Paid providers of goods or services to the program or having other financial interest <br /> in 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 <br /> interest does not necessarily make the project ineligible but the existence of <br /> '~^ funding, <br /> an undisclosed conflict may result in the termination of any grant awarded. <br /> Signature: ac4e_to 9 67 6o_c2c~uR 0 / / c / / , <br /> Executive Director Date <br /> / //&Signature: 0 / /��s <br /> Board Chairperson Date <br /> / <br /> Main Application 1/35/2016 2:29:32 PM Page 8 o f 9 <br />