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DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 <br />Exhibit A: Provider's Outside Agency Application <br />dj 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 />❑ E a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br />❑ Z 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 />❑ ❑ 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. <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 mpy result in the termination of any Arant awarded. <br />Signature: <br />Signature: <br />J -� <br />Date <br />Date <br />AGENCY INFORMATION 1/2312018 11:40:33 AM P 4; f <br />