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DocuSign Envelope ID: 16AB4DFA-7125-42E6-B3E7-C6B53151B77C 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 /> ❑ ® 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 /> ❑ ® 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 /> 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 /> G�a of. ( <br /> Signature: �/ 1/24/2016 <br /> Executive Director Date <br /> Signature: Phil Buchanan 1/24/16 <br /> Board Chairperson Date <br /> Main Application 1/25/2016 1:42:01 PM P a , o °1 4 o f 2 °1 <br />