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Page 8 of 23 <br />Are any of the Board Members or employees of the agency which will be carrying <br />out this program or members of their immediate families, or their business <br />associates… <br /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of the Town of Carrboro, <br />the Town of Chapel Hill, or Orange County? <br /> <br /> b) Members of or closely related to members of the governing bodies of <br />the Town of Carrboro, the Town of Chapel Hill, or Orange County? <br /> <br /> c) Current beneficiaries of the program for which funds are being <br />requested? <br /> <br /> d) Paid providers of goods or services to the program or having other <br />financial interest in the program? <br /> <br />If you have answered YES to any question, please provide a full explanation below. <br /> <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies <br />to the parties hereto for themselves, their agents, officials, employees and servants <br />agree not to discriminate in any manner of these basis of race, color, gender, <br />national origin, age, handicap, religion, sexual orientation, gender identity/ <br />expression, familial status or veterans status with reference to any activities carried <br />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 <br />Ordinance, as amended and the Orange County Anti-discrimination Policy. This <br />provision is enforced by action for specific performance, injunctive relief, or other <br />remedy as by law provided; this provision shall be binding on the grantees, the <br />successors and assigns of the parties hereto with reference to the above subject <br />manner. <br /> <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 any grant <br />awarded. <br /> <br /> <br />Signature: 1/23/18 <br /> Executive Director Date <br /> <br /> <br />Signature: 1/23/18 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 1263366F-0902-4D24-AE16-FC2EBB866669