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DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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 /> [11 L 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 /> E. c) Current benefibanies of the project/program for which funds are requested? <br /> Li 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 /> T. the Hst of my kno.,,HeAge and belkf all of the ab,Ilie information is true and <br /> current. I ackn wiedge and understand that the existence of a potential coi:Ilict 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: /1: 721, 1/25/2016 <br /> Executive. Director , - Date <br /> (- <br /> Signature: ,„ 1/25/2•16 <br /> oard Chairperson Date <br /> Main Application 1/24/2016 7:18:02 PM ci 1 2 2) f 1 2 <br />