[This letter must be printed on official institutional letterhead]
[Date]
Administrator of Grant Process Operations
North Carolina Biotechnology Center
15 T.W. Alexander Drive
P.O. Box 13547
Research Triangle Park, NC 27709-3547
Re:
[project title]
Dear NCBC:
In submitting this application, I certify that I have read and understand the information
and directions given in the [Program Name] application package and agree to be bound
by the conditions stated therein. I further certify that to the best of my knowledge, no
director or employee of the Biotechnology Center is a member of the Board of Directors
or other governing body of the applicant, nor does any such director or employee have a
direct or indirect ownership interest in the applicant, including the following:


no interest in excess of one percent of the equity of the applicant or with a
market value of more than $10,000;
no interest in excess of a 35% voting or profits interest in the applicant;
including any such interest owned by any such director’s or employee’s spouse, siblings,
spouses of siblings; ancestors, or children, grandchildren or great grandchildren or their
spouses; and any interest owned by an estate or trust in which such director or employee
has more than a 35% beneficial interest.
I further certify that to the best of my knowledge, no director or employee of the
Biotechnology Center has more than a 35% direct or indirect interest in any venture fund
or other investment instrument that in turn owns more than a 35% interest in the
applicant.
Sincerely,
[Name of Corporate Officer]
[Title of Corporate Officer]
RAL 332782v1