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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> provision and intent of Orange County Civil Rights Ordinance, as amended and the <br /> Orange County Anti-discrimination Policy. This provision is enforced by action for <br /> specific performance, injunctive relief, or other remedy as by law provided; this <br /> provision shall be binding on the grantees, the successors and assigns of the parties <br /> 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 <br /> interest does not necessarily make the program ineligible for funding, but the <br /> existence of an undisclosed conflict may result in the termination of any qrant <br /> awarded. <br /> Signature: 'n \ N, 1 e--0)1,A <br /> Executive Director Dat <br /> / 1/A—, r <br /> Si at re: '' ( `---- /Vei'' , 01/31/2017 <br /> g <br /> Board Chairperson Date <br /> AGENCY INFORMATION 2/9/2017 1:10:02 PM P 3 g l" 9 3 0 3 8 <br />