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DocuSign Envelope ID: 8E8982E7 -EFF8- 4214- 979D- 9D572ED220CC <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON <br />DISCRIMINATION CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out this <br />program or members of their immediate families, or their business associates? <br />YES NO <br />❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br />❑ ® 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 />❑ ® 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, <br />handicap, religion, sexual orientation, gender identity /expression, familial status or veterans <br />status with reference to any activities carried out by the grantee, no matter how remote. <br />The parties hereto further agree in all respects to conform to the provision and intent of <br />Orange County Civil Rights Ordinance, as amended and the Orange County Anti- <br />discrimination Policy. This provision is enforced by action for specific performance, <br />injunctive relief, or other remedy as by law provided; this provision shall be binding on the <br />grantees, the successors and assigns of the parties hereto with reference to the above <br />subject manner. <br />To the best of my knowledge and belief all of the above information is true and <br />current. I acknowledge and understand that the existence of a potential conflict of <br />interest does not necessarily make the program ineligible for funding, but the <br />existence of an undisclosed conflict may result in the termination of anv arant <br />awarded. <br />Signature: N/A <br />Executive Director <br />Signature: /e%'6tutZei� <br />Date <br />1/17/2018 <br />Board Chairperson Date <br />AGENCY INFORMATION 2/11/2018 4:28:29 PM Page 7 of 26 <br />