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DocuSign Envelope ID: E9DE81F9-0070-4074-8F70-93DABC24ACE1 L 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 project, or <br /> 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 /> 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 /> Board member Elisabeth Johnson's partner Kennard Winchester is a school bus driver for the <br /> Chapel Hill Carrboro City Schools and works as a basketball coach for the Phillips Middle School <br /> boys team. <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: //2„cti/C2 <br /> Executive Director Date <br /> Signature( - t_LA (A,2 1 V ([5,1A/LA---,.., J7. L_ I Lr, <br /> oard Chairperson Date <br /> Main Application 1/24/2016 2:59:42 PM Page 1 6 of 58 <br />