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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 />Signature: <br />Signature: <br />Executive Director Date <br />Board Chairperson Date <br />Main Application 2/11/2016 9:12:15 AM Page 13 of 20 <br />