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Cover Page Page 6 of 20 <br /> <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 /> <br /> <br />Signature: 12/20/2022 <br /> Executive Director Date <br /> <br />Signature: 1/10/2023 <br /> Board Chairperson Date <br /> <br />Application Signatures: Please submit a wet signature or electronic signature , MS <br />Word cursive fonts are not acceptable. <br />DocuSign Envelope ID: A24D2229-012E-4233-A6F8-624A53BCF7DA