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DocuSign Envelope ID: 10F0B4DA-C8B5-4AB3-9AFA-939AE0010B18 (HIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTE1 :TIAL CONFLICTS OF INTEREST ND 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 /> J 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 Carrboro, <br /> the Town of Chapel Hill, or Orange County? <br /> H c) Current beneficiaries of the program for which funds are being requested? <br /> H 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 /> NON-DISCRIIIINATiON <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 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 performance, injunctive relief, or other remedy as by law <br /> 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 belitf all of the alhove inform lion is true and c, ,rrent, <br /> I acknowledge and understand that the existence of a potential conflict of interest does not <br /> necessarily make the program ineligible for funding, but the existence ':f an undisclosed <br /> conflict ma, result i the termination of an 1,rant ,,warded, <br /> / <br /> Signature: / / <br /> / 4//// (//t <br /> e6iltiveirector Date <br /> Signature: <br /> Yoartt Chairperson Date <br /> AGENCY INFORMATION 1127/2017 3:01:18 PM , i <br />