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DocuSign Envelope ID: D13694BA-66F1-4441-9114-5334F2B6AC3D 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 /> LI a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> LI 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 /> c) Current beneficiaries of the program for which funds are being requested? <br /> LI <br /> 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 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 belief all of the above information is true and current. <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 of an undisclosed <br /> conflict may result in the termination of any grant awarded. <br /> Signature: I - <br /> Executive Director Date <br /> Signature: ' /. 3,1 /7 <br /> Boa Chairperson Date <br /> AGENCY INFORMATION 1/26/2017 1:47:36 PM , r <br />