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DocuSign Envelope ID: 3CD68914-055B-4274-9AF2-A50FD766FB76 t A - continued <br /> ProviderVAsiOrkwhowlication <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 /> LI b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> LI Z c) Current beneficiaries of the project/program for which funds are requested? <br /> z 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 /> Nicole Hunter, with whom we contract to run the Every Girl Counts middle school group, is married <br /> to John French, who works for the town of Chapel Hill. <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: r/e"..a.ft.-47- <br /> xecutive Dire ir Date <br /> Signature: 111, <br /> 1121/2,01t, <br /> Boarai hairperson Date <br /> Main Application 1/21/2016 10:04:57 AM Page 16 of 2 1 <br />