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DocuSign Envelope ID:E519448F-9F6D-4100-BF62-D7625621FFEB 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 interest <br /> does not necessarily make the program ineligible for funding, but the existence of an <br /> undisclosed conflict may result in the termination of any grant awarded. <br /> Signature: <br /> Executive Director Date <br /> --- <br /> Signature: , 5 -.7 _ <br /> (-- <br /> ( / 3 / // --? <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/31/2017 9:32:10 AM Page 9 of 24 <br />