Orange County NC Website
Browse       Search
DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> l.) 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 /> r a)Employees of or closely related to employees of the Town of Chapel Hill, Orange County, <br /> Carrboro, or Hillsborough? <br /> El 14,, b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, <br /> Hillsborough, or Orange County? <br /> El c) Current beneficiaries of the project/program for which funds are requested? <br /> El X1 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 current. <br /> I acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the project Ineligible for funding, but the existence of an undisclosed <br /> conflict may result in the termination of any grant awarded, <br /> /e/71/11, <br /> Executive Director Oat <br /> Signature: eie4-44- /1-c-i-e744 0.1 0-0 <br /> Board Chairperson Date <br /> Main Application 1/21/2016 2:00:34 PM Page 1 0 of 1 6 <br />