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AGENCY INFORMATION 1/23/2018 3:25:53 PM Page 3 of 22 <br /> <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br />CLAUSE <br /> <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 /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br /> <br /> b) Members of or closely related to members of the governing bodies of the Town of <br />CarrboFYro, the Town of Chapel Hill, or Orange County? <br /> <br /> c) Current beneficiaries of the program for which funds are being requested? <br /> <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 /> <br /> <br /> <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br />hereto for themselves, their agents, officials, employees and servants agree not to discriminate in <br />any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual <br />orientation, gender identity/expression, familial status or veterans status with reference to any <br />activities carried out by the grantee, no matter how remote. The parties hereto further agree in all <br />respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended <br />and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific <br />performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on <br />the grantees, the successors and assigns of the parties hereto with reference to the above subject <br />manner. <br /> <br /> <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 /> <br /> <br />Signature: 1/23/2018 <br /> Executive Director Date <br /> <br />Signature: 1/23/2018 <br /> Board Chairperson Date <br />