Orange County NC Website
Browse       Search
DocuSign Envelope ID:A65EF081-BF54-47AC-9969-94226D3FBC7E 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 <br /> project, or members of their immediate families, or their business associates: <br /> YES NO <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 <br /> interest 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 current. I <br /> acknowledge and understand that the existence of a potential conflict of interest does <br /> 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: 1/22/2016 <br /> Executive Director Date <br /> Signature: f 1/22/2016 <br /> and Chairperson Date <br /> m.)Work Statement <br /> This form is used to document program activities, program goals, performance measures, and <br /> actual results. (Add more rows as needed) If this is a new program, you will only document the <br /> projected information. <br /> • Program Activities should outline major activities the agency implements to accomplish its <br /> program goals. <br /> • Program Goal should explain what the program is trying to achieve/accomplish. Goals are <br /> statements about what the program should accomplish. SMART Goals <br /> • Performance Measures describe how you will evaluate the degree in which you achieved the <br /> stated goals. <br /> • Actual Program Results use program results to indicate the actual measureable <br /> achievement of goals. If goals were not met, please explain. <br /> Main Application 1/25/201 6 1 2:11 :11 PM <br />