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DocuSign Envelope ID:6D821DA0-CO6F-4D38-BB4F-DB28CB54AD8E XHIBIT 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 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 /> 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 interest <br /> 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 to <br /> the parties hereto for themselves, their agents, officials, employees and servants agree <br /> not to discriminate in any manner of these basis of race, color, gender, national origin, <br /> age, handicap, religion, sexual orientation, gender identity/expression, familial status or <br /> veterans status with reference to any activities carried out by the grantee, no matter how <br /> remote. The parties hereto further agree in all respects to conform to the provision and <br /> intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti- <br /> discrimination Policy. This provision is enforced by action for specific performance, <br /> injunctive relief, or other remedy as by law provided; this provision shall be binding on the <br /> grantees, the successors and assigns of the parties hereto with reference to the above <br /> subject manner. <br /> To the best of my knowledge and belief all of the above information is true and current. I <br /> acknowledge and understand that the existence of a potential conflict of interest does <br /> 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. <br /> Signature: � ,` =' 1/28/17 <br /> Execu lve Director Date <br /> Signature: (5 - ' " ' 1/28/17 <br /> Board Chairpe son Date <br /> Agency Information 1/31/2017 8:24:51 AM Page 1 of 20 <br />