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DocuSign Envelope ID: C47D73DC -CC50- 4723 - 8253- AE01785E7FAA <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 />❑ ® 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 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 />Michael Parker, our Board Chair, is on the Chapel Hill Town Council. <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 arant awarded. <br />Signatu <br />x a Dire#r <br />Signature: <br />� "�f. �. ^,- <br />Board Chairperson <br />jz� <br />Date <br />Date <br />12,3 12.4 / y <br />AGENCY INFORMATION 1/22/2018 4:56:17 PM Page 8 of 23 <br />