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DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4 -6l A6E4C39BD2 ' Wr 2J 1� l..y VYi 1141 f VV111 "J 1.0211 y11 Km. VLAt a n.4 FA U91 ell! l Ul <br />members af��r�at�Tr�irI�eiiirasY APPLICATION ff <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 <br />Carrboro, the Town of Chapel Hill, or Orange County? <br />U 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 <br />the 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. I <br />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 />F . ---1 0 % , . ( j - - <br />Signature: <br />xecutive Dire ` � R <br />A4 _RaSignature: _ <br />Bo 4 hairper on <br />l <br />-.-7 <br />Date <br />Date <br />AGENCY INFORMATION 2/112017 9:01:31 AM P a g e 8 o f 2 3 <br />