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DocuSign Envelope ID: 28872B9E- 993A- 44CA- 8A5E- OBDA1F6178CB <br />Exhibit A: Provider's Outside Agency Application <br />MAIN APPLICATION <br />l.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br />Are any of the Board Members or employees of the agency which will be carrying out this <br />project, or 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 />• n b) Members of or closely related to members of the governing bodies of Chapel Hill, <br />Carrboro, Hillsborough, or Orange County? <br />0 ® c) Current beneficiaries of the project /program for which funds are requested? <br />❑ o d) Paid providers of goods or services to the program or having other financial interest <br />in 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 <br />interest does not necessarily make the project ineligible for funding, but the existence of <br />an undisclosed conflict may result in the termination of anv grant awarded. . <br />- <br />Date <br />Main Application11127 /2017 8:44:40 PMP ge 17 of 25 <br />