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DocuSign Envelope ID: DD554565-B9BA-4128-863D-805D6BC56619 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 /> LII b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> 110 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 /> 1. Colleen Bridger and her designee, Meredith Stewart, are employees of the Orange County <br /> Health Department, <br /> 2, Mark Dorosin is a county commissioner designated by the Board of County Commissioners to <br /> serve on our Board of Directors. <br /> 3, Tom Forcella is superintendent of Chapel Hill/Carrboro City Schools. His designee, Kerry <br /> Moore, director of Head Start and Pre-K, serves in his absence, <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 qrant awarded. <br /> ,/ <br /> Signature: 1/25/16 <br /> Executive Director Date <br /> Signature: 1/25/16 <br /> Board Chairperson Date <br /> Main Application 1/25/2016 10:25:47 AM H ; 1 4 c 2 1 <br />