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DocuSign Envelope ID: 5BF9183D-3BD5-4FD7-80DE-F437539D2E9F 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 ' 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 /> E] I c) Current beneficiaries of the project/program for which funds are requested? <br /> [1] 11 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 /> -----_ <br /> \ N <br /> Signature <br /> Executive Director \ <br /> )(---Z7— It 2 --1 ' <br /> Signature: e c q -, ,, i (:),,,t >,-e,-- , Di al ,,),,[4\ ): <br /> , 2(( //// (/'/,,/ e" ,.., <br /> Board Chairperson Date <br /> Main Application 1/13/2016 3:04:09 PM ' ,i ci cs I 0 ) r ; c, <br />