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DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E 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 /> El IS] a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> El b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> LI 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 <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: cl..11A 2-6) <br /> E 4utivp pirtr,i Date <br /> , <br /> Signature: ) <br /> / 2-C; <br /> Board Cha4-persbn Date <br /> Main Application 1/25/2016 10:16:09 AM Page 1 2 of 20 <br />