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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> c) To the best of my knowledge and belief all information and data in this <br /> application is true and current. The document has been duly authorized by the <br /> governing board of the applicant. <br /> M <br /> Signature: \ 'IN, 1 e--0)1,A <br /> Executive Director Dat <br /> r it _ r <br /> 1 <br /> ." ' ( ` -- `"// , 01/31/2017 <br /> Si Hato re ° - <br /> Board Chairperson Date <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 /> ❑ X a) Employees of or closely related to employees of the Town of Carrboro, the <br /> Town of Chapel Hill, or Orange County? <br /> ❑ X 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 /> ❑ X c) Current beneficiaries of the program for which funds are being requested? <br /> ❑ X 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 /> AGENCY INFORMATION 2/9/2017 1:10:02 PM II:' M:1 y 8 3 :;r II J 8 <br />