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DocuSign Envelope ID: 2F546B53- F2D1- 407D- A1C7- 26EB823DOFFD <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 />0■ <br />® a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br />Chapel Hill, or Orange County? <br />El Z 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 Z cj Current beneficiaries of the program for which funds are being requested? <br />El Z d) Paid providers of goads 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 ail respects to conform to the provision and intent of Orange County Civil Rights <br />Ordinance, as amended and the Grange 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 />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 />Signature: <br />u �W L! J'Z_ <br />E utive Direct Date <br />I -I, a <br />card Chairperson Date <br />_.._.... �..._._..__......._ ......_...... -. _ ............_......_._.._ .., .. _.__._..._.. - — - ........ __................ _......_.... <br />AGENCY INFORMATION 1122/2018 11:03:58 AM Page S of 29 <br />