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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> (3) 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 /> L ❑ 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 /> El ® 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 /> The two part time assistants are teachers employed by the Chapel Hill-Carrboro School district <br /> during the school day but are employees of the Boys & Girls Club Program for Impact <br /> during the Club after-school hours. We are applying for funds to help pay the <br /> salaries/benefits of the two part-time employees as well as for the Program Director (who <br /> is not employed by the schools- is 100% employed by BGCDOC) <br /> NON-DISCRIMINATION <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. <br /> /7 , ,„,,„ <br /> :- "f*,'z�. '.y' �,,,.TY.rC"', , i ,,f q A N / do,/ <br /> Signature: _ <br /> Ec Live Director Date <br /> �� i2'l `�i' '� <br /> Signature: A �` ' / /z7/-7.-- <br /> Board Chairperson U Date <br /> AGENCY INFORMATION 1/26/2017 14:54:11 al/pi P a g e 7 of 22 <br />