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DocuSign Envelope ID: 1381 F24A-F27B-438F-AC45-7A1 6015EA606 _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 current. <br />I acknowledge and understand that the existence of a potential conflict of interest does <br />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 />Signature: <br />AGENCY INFORMATION <br />Date <br />oil <br />Date <br />1/8/2018 10:00:15 AM Page 10 of 25 <br />