Orange County NC Website
Browse       Search
DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <br />EXHIBIT A: 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 />❑ 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 />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 <br />in 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 identitylexpression, 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 />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 anv Grant awarded. <br />Signature: t / \ L <br />Director Date <br />Signature; U{�' r�t L t- 2 � -/t <br />Board thairperson Date <br />AGENCY INFORMATION 1119/2018 12:42:41 PM Page 2 of 1 1 <br />