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DocuSign Envelope ID:990F6965-575D-4E0D-A54F-9DAD6D65198E t A - continued <br /> Provider's GA ,mlication <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 /> YESNO <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 the <br /> 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 /> ;r .,�� <br /> Signature: " , t <br /> ,Executive Director Date <br /> Signature: � / - 2G -/6 <br /> :oard Chairperson Date <br /> Main Application 1/26/2016 5:06:15 PM Page 1 3 of 2 1 <br />