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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br /> CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this program <br /> or members of their immediate families, or their business associates... <br /> YES NO <br /> n ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> ❑ b) Members of or closely related to members of the governing bodies of the Town of <br /> Cerrboro, the Town of Chapel Hill, or Orange County? <br /> ❑ ® c) Current beneficiaries of the program for which funds are being requested? <br /> ❑ ® 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 /> NONDISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the <br /> parties hereto for themselves, their agents, officials, employees and servants agree not to <br /> discriminate in any manner of these basis of race, color, gender, national origin, age, <br /> handicap, religion, sexual orientation, gender identity/expression, familial status or veterans <br /> status with reference to any activities carried out by the grantee, no matter how remote. The <br /> parties hereto further agree in all respects to conform to the provision and intent of Orange <br /> County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination <br /> Policy. This provision is enforced by action for specific performance, injunctive relief, or other <br /> remedy as by law provided; this provision shall be binding on the grantees, the successors <br /> and assigns of the parties hereto with reference to the above subject manner. <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 interest <br /> does 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. E' <br /> Signature: /4' 7 ;20 t7 <br /> Exec Director Date <br /> Signature: Viairperson-. / 3 / <br /> � _A Bo Date <br /> AGENCY INFORMATION__.-_......_._____..- 1/27/2017 11:59:25 AM Page 3 o f <br /> 1� <br />