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DocuSign Envelope ID:4F0B7605-00EB-4D90-837E-574BBBBD89EB 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 /> II XXE a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> n XXLIIJ b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> Lii xx- 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 <br /> 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 <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 /> () <br /> Signature: ( <br /> Executive Director Date <br /> Signature: 1- 2 -tL <br /> Board Chairperson Date <br /> Main Application 1/21/2016 2:14:46 PM P g I 5 o t 2 <br />