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To the best of my <br />knowledge and belief <br />all of the above <br />information is true <br />and current. I <br />acknowledge and <br />understand that the <br />existence of a <br />potential conflict of <br />interest does not <br />necessarily make the <br />program ineligible for <br />funding, but the <br />existence of an <br />undisclosed conflict <br />may result in the <br />termination of any <br />grant awarded. <br />checked <br />A12. Primary Contact <br />Name <br />Laura <br />Dille <br />A13. Primary Contact <br />Title <br />Director of Operations <br />A14. Primary Contact <br />Preferred Phone <br />Number <br />+19196364860 <br />A15. Primary Contact <br />Email Address <br />ldille@tablenc.org <br />A16. Chief Executive <br />Officer / Executive <br />Director <br />Ashton <br />Tippins <br />A17. Chief Executive <br />Officer / Executive <br />Director Title <br />Executive Director <br />A18. Chief Executive <br />Officer / Executive <br />Director Preferred <br />Phone Number <br />+19196364860 <br />A19. Chief Executive <br />Officer / Executive <br />Director Email <br />Address <br />actippins@tablenc.org <br />A20. Date of <br />Incorporation <br />(Month/Year): <br />07/2008 <br />Docusign Envelope ID: 607995AB-FD72-4B81-91C2-2C0A73A91963