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DocuSign Envelope ID:C8F16CD1-FF19-486F-8DD6-57316D1FCD54 <br /> EXHIBIT A - PROVIDERS OUTSIDE AGENCY APPLICATION <br /> d) IlliSCLOSURE OF PO 1 Ell "i 1 II1L 0 ,01NFLICTS SE 1, 1111. 111-S ,111 ISC <br /> wl USE <br /> Are a ly of the Board embers or e liployees of the agency hich will se crrying out this program or <br /> embers of their ediate families, or their business associates ES 12Q <br /> L a) Employees of or closely related to e ployees If the Tow of Carrboro, the To n of <br /> Chapel Hill, or Or-nge County? <br /> h) lei hers of or closely related to me lhers of the gover ing bodies of the Tow of C. rrboro, <br /> the Town of Chapel Hill, or Orange County? <br /> [I] X c) Current benefici-ries of the program for which funds re being requested? <br /> d) Paid providers f goods or services t the program or hiving other fins l cial interest in the <br /> program? <br /> If you have ens ere YES to any question, 101 s pr.vide f II exil ti hn 1,1 <br /> 01110111-DISC1,111111 <br /> Provider agrees as part of consideration of the grant g of funds by funding agencies to the <br /> parties hereto for ter Iselves, their agents, officials, employe-s and servants agree not to <br /> discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, <br /> religion, sex lel rientation, gen ler identity/expression, familial status or veter ins status with <br /> reference to any--ctivities carried out by the grantee, II lafter ho rern.te, The parties hereto <br /> further agree in II respects to •nforr to the provision and intent of Orange County Ci il Rights <br /> Ordinance, as a nded and the Orange County Anti-discrimination Policy. This provisio is <br /> enforced by ctio for specific performance, injunctive relief„ or other re ledy as by la <br /> provi led; this pro ision shall be binding on the lumtees, the success IS and assi,ins of the <br /> parties hereto with referenct to the above s bject wanner. <br /> T tos :t fir,11 kn e n• v Ji f II iT th s iT,ir ati n is tr dl c rre iL <br /> er tal tht th ist . c, Jip intl..] on i t of int IA'.1+st 1ses it <br /> 111111.c.ss,riiy 11-ile the II r 1,1r. 11 inliç le fir f ify ding, IlittieL istel2o. of nn.L_d 1011 clIlLtk. <br /> liCt 4 II ay result J the it.ro .1pLaraly <br /> Siint, <br /> Executive Director Date <br /> - /- <br /> Sign-.41 re: 1 <br /> 1^1 oard Chairp0••.rs n Date <br /> AGE CY PI FOR AT1011 1/24/201'7 9:38:26 AM / <br />