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DocuSign Envelope ID:E519448F-9F6D-4100-BF62-D7625621FFEB XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> d) 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 or <br /> members of their immediate families, or their business associates... <br /> YES NO <br /> Z | a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> Z b) Members of or closely related to members of the governing bodies of the Town of Carrboro, <br /> the Town of Chapel Hill, or Orange County? <br /> -- 14 c) Current beneficiaries of the program for which funds are being requested? <br /> C 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 /> Orange County Commissioner Mia Burroughs is a board member, appointed by the County <br /> Commissioners to the OCPYC Board of Directors; Board member Colleen Bridger and her <br /> designee Coby Austin are employees of the Orange County Health Department; Board <br /> member Lucinda Munger leads the Orange County Library; Todd Wirt, superintendant of <br /> Orange County SChools, and Kerry Moore, director of CHCCS Head Start and Pr8-K, serve <br /> On the board; Emily Bivins is an employee of the CHCCS. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the <br /> parties hereto for themee|ven, their ogento, nffioia|s, employees and servants agree not to <br /> discriminate in any manner of these basis of race, oo|or. Bender, national nrigin, oge, hondimap, <br /> re/i0ion, sexual orientoUon, gender identity/expnesoion, familial status or veterans status with <br /> reference to any activities carried out by the grantee, no matter how remote. The parties hereto <br /> further agree in all respects to conform to the provision and intent of Orange County Civil Rights <br /> Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is <br /> enforced by action for specific perfonnonce, injunctive na|ief, or other remedy as by law <br /> provided; this provision shall be binding on the 0nanteem, the successors and assigns of the <br /> parties hereto with reference to the above subject manner. <br /> AGENCY INFORMATION 1/31/2017 3:59:06 PM P a g e 5 of 18 <br />