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DocuSign Envelope ID:D2CB2439-4B3B-42E7-A090-286FDDD6E948 - continued <br /> Provider's Outside Agency 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, <br /> or members of their immediate families, or their business associates: <br /> D XE a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> El XLI b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> LI XE c) Current beneficiaries of the project/program for which funds are requested? <br /> LI XE-1 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 for funding, but the existence of <br /> .nundisclo a I I. LPL i i.• 7 rmi tt aw, • -I!. <br /> Signature: <br /> Kevin J N6ortan, Executive Director Date 22 January 2016 <br /> d - <br /> Signature: /4' , /4 <br /> Rev, Nathan AVan Hollister, Board Chairperson Date 22 January 2016 <br />