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DocuSign Envelope ID:2164F437-BF9D-46A1-B13B-7740B02003DA - continued <br /> ProviderMs0A98wil4 A plication <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 El a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> Li El b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> El:. c) Current beneficiaries of the project/program for which funds are requested? <br /> Ell Cl 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 /> The two part time staff are teachers employed by the Chapel Hill-Carrboro School district during <br /> the school day but are employees of the Boys & Girls Club during the Club after school hours. <br /> We are applying for funds to help pay the salaries/benefits of the two part time employees as well <br /> as for the Program Director (who is not employed by the schools- is 100% employed by BGCEP). <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 ma result in the termination of an •rant awarded. <br /> Signature: / (/ he a <br /> xecutive irector Date <br /> j <br /> Signature: \, ,It 6 /if 7„e)4 <br /> ard Chair rson Date <br /> Main Application 1/13/2016 12:06:34 al/p1 , e 16 of 22 <br />