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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 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 program or <br /> 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 Town of <br /> Chapel Hill, or Orange County? <br /> ❑ x 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 /> ❑ 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 interest in the <br /> 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 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, handicap, <br /> religion, sexual orientation, gender identity/expression, familial status or veterans status with <br /> reference to any activities carried out by the grantee, no matter how remote. The parties <br /> hereto further agree in all respects to conform to the provision and intent of Orange County <br /> Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This <br /> provision is enforced by action for specific performance, injunctive relief, or other remedy as by <br /> law provided; this provision shall be binding on the grantees, the successors and assigns of the <br /> 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 /> Signature: Gail Abrams 01/30/2017 <br /> Executive Director Date <br /> Signature: Martha Wewer 01/30/2017 <br /> Board Chairperson Date <br /> 1/12/2017 2:56:42 PM Page 5 •f 29 <br />