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DocuSign Envelope ID:9B26E979-2C09-4BE7-801C-3DDB484D92EE XHIBIT A <br /> PROVIDER"S OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br /> cLo4usE <br /> Are any of the Board Members or employ,-s of the agency which will be carrying out this program <br /> or members of their immediate fairrillies, or their business associates„ <br /> YES NO <br /> X0 l: a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> El 0 b) Members of or closely relat;,ii to members of the governing bodies of the Town of <br /> Carrboro the Town of Chapel Hill, or Orange County? <br /> , , <br /> [:::1 Li c) Current beneficiaries of the program for which funds are being requested? <br /> r: [J 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 /> Archie Daniel is a i part-time employee of the Sheriffs Office, responsible for leading the SALT <br /> program, He s a volunteer with OCRA,and receives no compensation. <br /> NON-DiscRirteNATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br /> hereto for themselves, their agents, officials, employees and servants agree not to discriminate in <br /> any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual <br /> orientation, gender identity/expression, familial status or veterans status with reference to any <br /> activities carried out by the grantee, no matter how remote, The parties hereto further agree in all <br /> intent . <br /> respects to conform to the provision and ntent of Orange County Civil Rights Ordinance, as <br /> amended and the Orange County Anti-discrimination Policy, This provision is enforcz,* by action for <br /> specific performance, injunctive relief, or other remedy as by law provided; this provision shall be <br /> „ <br /> binding on the grantees, the successors and assigns of the parties hereto with reference to the <br /> 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 :,xisterice of a potential conflict of Interest <br /> does not necessarily make the program ineligible for funding, but the existence of an <br /> .. <br /> undisclosed conflict may r :lult in the termination of any grant awarded. <br /> Signature: _ <br /> Norma B.White Jan. 26 2017 <br /> „ ...... _ . , ... , <br /> Executi Director Date <br /> Alex <br /> Signature: Alex Cat5tro JR Jan. 26 2017 <br /> , <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/26,2017 342:32 PM ill a g e 4 () I 1 7 <br />