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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <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 <br /> interest does not necessarily make the program ineligible for funding, but the <br /> existence of an undisclosed conflict may result in the termination of any qrant <br /> awarded. <br /> Signature: 7 1/30/17 <br /> Executive Director Date <br /> Signature: � , 1/30/17 <br /> Board Chairperson Date <br /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 11 ,D 31 <br />