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DocuSign Envelope ID: 8FFCF3D9- 3AF5 -4C83- 9829- AC9D4975107C <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND ICON DISC RIMINATION <br />CLAUSE <br />Are any of the Board Members or employees of the ageroy which will be carrying out this program <br />or membm of their immediate families, or their business associates... <br />YES NO <br />E) X a) Employees of or closely related to employees of ttre Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br />El X b) Members of or closely related to members of the governing bodies of the Town of <br />Carrboro, the Town of Chapel Hall, or Orange County? <br />E] X c) Current beneficiaries of the program for which funds are being requested? <br />® X d) Paid providers of goods of services to the program or having other financial interest it <br />the program? <br />If you have answemd YES to any question, ptbase provide a full explanation Wow. <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 riot to <br />discriminate in any manner of these basis of race, color, gender, nadional olrlgin, Ten <br />handicap, religion, sexual orieritation, gender identitylexpression, 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 agme in all respects to conform to the provision and intent of Orange <br />County Civil fights Ordinance„ as amended and the Orange Cou Anti- discrimination <br />Policy. This provision is enforced by action for specific performance. injunctive relief, or othe <br />remedy as by lawn provided; this provision small be Winding on the grantees, the successors <br />and assigns of the parties hereto with refemnoe to the above subject manner. <br />To the bmt of my knowledge and belief all of the above information is tnym and <br />current I acknowledge, and 'undemtantl that the existence of a potential conflict of interest <br />does not necessarily rake the program ineligible for funding, but the existence of an <br />undisclosed conflict t in the termination of a nt_awarded. - <br />Signature: <br />Date <br />Signature, <br />Board ChairpawQV Date <br />AGENCY INFORMATION 2 t i Bt8 1013,36 AM P a g e 10 :) t 40 <br />