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DocuSign Envelope ID: E7F88FC1-7C61-4E68-8AF9-5870F711DEBC it A continued <br /> Provider's Outside Agency Application <br /> 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 /> ❑ Z a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, <br /> Carrboro, or Hillsborough? <br /> ❑ Z b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, <br /> Hillsborough, or Orange County? <br /> ❑ ® c) Current beneficiaries of the project/program for which funds are requested? <br /> ❑ Z 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 current. <br /> I acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the project ineligible for funding, but the existence of an undisclosed <br /> conflict may result in the termination of any grant awarded. <br /> Signature: <br /> E e uti i recto r Dat <br /> Signature: Carat <br /> Board Chairperson Date <br /> Main Application 1/25/2016 1:23:46 PM Page 1 6 o f 26 <br />