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DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D <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 />❑ ® 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 Carrboro, <br />the Town of Chapel bill, or Orange County? <br />Z 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 may result in the termination of any grant awarded. <br />Signature: <br />Executive Director <br />Iii "^- - C_�• fit- �� -' <br />Signature: _ <br />Board Chairperson <br />L' E'' x <br />Dat <br />Date <br />l /'l i /t<� <br />AGENCY INFORMATION 1 /9/2018 2:46:51 PM Page 8 of 23 <br />AGENCY INFORMATION 1/22/2018 3:23:54 PM Page 10 of 27 <br />