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DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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 /> Eg a)Employees of or closely related to employees of the Town of Chapel Hill, Orange County, <br /> Carrboro, or Hillsborough? <br /> Li b)Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, <br /> Hillsborough, or Orange County? <br /> LII 121 c) Current beneficiaries of the project/program for which funds are requested? <br /> 0 •4 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 bel. <br /> To the best of my knowledge and belief all of the above info ation is true and current. <br /> I acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the project ineligible for funding, but the existence of an undisclosed <br /> conflict may result in the termination of any grant awarded. <br /> Signature: ft v i.,* 1911111 <br /> Executive •irector Oat <br /> Signature: Wil - 411 ' 1/20/1/0 <br /> Board Ch l rperson Date <br /> Main Application 1/19/2016 11:43:02 AM Page 11 of 1 9 <br />