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oocunignsnvelopo 0:oeoee1a4'one7-4aca*nrA-CmnAcocoeeco Exhibit /\ - continued <br /> Provider's J\nplication <br /> !.} DISCLOSURE OF POTENTIAL CONFLICTS QFINTEREST <br /> Are any of the Board Members or employees o,the agency which will ua carrying out this project, or <br /> members of their immediate families,or their business associates: <br /> YES NO <br /> F] 7 o) Employees of or closely related to employees of the Town of Chapel H0. Orange <br /> County, carrbonp.or Hillsborough? <br /> u> Members of or closely related to members of the governing bodies of Chapel Hill. <br /> Canuono. Hillsborough, nr Orange County? <br /> �J *Current beneficiaries of the pnVunUpmg,nm for which funds are requested? <br /> [� <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 /> To the best of my knowledge and belief all of the above information 1s true and <br /> current. | acknowledge and understand that the existence ofm potential conflict mfinterest <br /> uv*a not necessarily make the project ineligible for yunmimg, but the existence of an <br /> awarded,undisclosed conflict mav result in the termination of aln grant <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> Beard ChairpersQrC Date <br /> Main Application 1124/20185:04:30PNl Pa�e 1 � of 39 <br />