Orange County NC Website
Browse       Search
DocuSign Envelope ID:A3E0213B-1DCD-43A3-9C41-A2EC55A8CA94 A - continued <br /> Provider's mflopEia/ pcation <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 /> • r ; Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> • 7b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> Current beneficiaries of the project/program for which funds are requested? <br /> • Vd) 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 /> Signature: (p_eiv) & & j ) <br /> Executive Director ate <br /> Signature: afr(---71- <br /> Board Chairperson D te <br /> Main Annliratinn 1121/7n1R Q-'R7. 7 AM P :atin I r f 9 9 <br />