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DocuSign Envelope ID:BF9F1016-CEDB-4BF6-9DF2-A6DAB623164C 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 project, or <br /> members of their immediate families, or their business associates: <br /> YES NO <br /> EJ 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 /> [3 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 interest in <br /> the program? <br /> If you have answered YES to any question, please provide a full explanation below. <br /> CEF has incorporated into our By-Laws the requirement that at least one former or current <br /> beneficiary (Member) of our program serve on the Board of Directors at all times. Currently, two <br /> Members serve on the Board of Directors. These members of the Board of Directors provide <br /> invaluable advice based on their particular experiences working with the organization directly, and <br /> like all members of the Board of Directors, sign an annual conflict of interest disclosure outlining any <br /> potential conflicts that may arise based on their dual relationship with the organization, <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 /> 1 ( <br /> Signature: <br /> Executive oirector Date <br /> 3 <br /> Signature: / 1 c <br /> Board Chairperson Date <br /> Main Application 1/24/2016 1:47:35 PM R I 5 c 2 1 <br />