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DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />dj DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NONDISCRIMINATION <br />CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out this program <br />or members of their immediate families, or their business associates... <br />YES NO <br />❑ Z 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. The <br />parties hereto further agree in all respects to conform to the provision and intent of Orange <br />County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination <br />Policy. This 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 successors <br />and assigns of the 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 <br />current. I acknowledge and understand that the existence of a potential conflict of interest <br />does not necessarily make the program ineligible for funding, but the existence of an <br />undisclosed conflict may result in the termination of any grant awarded. <br />R� <br />Signature'."°' <br />Executive Di or <br />Signature.'b <br />' Board Chairperson <br />ter' <br />Date <br />/ /0;Z?- c C i <br />Date <br />AGENCY INFORMATION 1/22/2018 10:21:29 AM Page of 31 <br />