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DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON <br /> DISCRIMINATION CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this <br /> program or members of their immediate families, or their business associates... <br /> YES NO <br /> ❑ © a) Employees of or closely related to employees of the Town of Carrboro, the <br /> Town of Chapel Hill, or Orange County? <br /> ❑ © b) Members of or closely related to members of the governing bodies of the Town <br /> of Carrboro, 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 <br /> interest in the program? <br /> If you have answered YES to any question, please provide a full explanation below. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies <br /> to the parties hereto for themselves, their agents, officials, employees and servants <br /> agree not to discriminate in any manner of these basis of race, color, gender, national <br /> origin, age, handicap, religion, sexual orientation, gender identity/expression, familial <br /> status or veterans status with reference to any activities carried out by the grantee, no <br /> matter how remote. The parties hereto further agree in all respects to conform to the <br /> provision and intent of Orange County Civil Rights Ordinance, as amended and the <br /> Orange County Anti-discrimination Policy. This provision is enforced by action for specific <br /> performance, injunctive relief, or other remedy as by law provided; this provision shall be <br /> binding on the grantees, the successors and assigns of the parties hereto with reference <br /> 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 <br /> interest does not necessarily make the program ineligible for funding, but the <br /> existence of an undisclosed conflict may result in the termination of any grant <br /> awarded. / 07- <br /> Signature: <br /> EOcutive Director Date <br /> Signature: _L/ <br /> Board Cha rerson Date <br /> Page s of 20 <br />