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DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A <br /> 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 ardency which will be carrying out this program <br /> or members of their immediate families, or their business associates... <br /> YES ISO <br /> 0 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 /> Q 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 mariner of these basis of race, color, gender, national origin, age, <br /> handicap, religion, sexual orientation, gender identityfexpression, 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 Change <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 ether <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 exist ncq__!Pf._Rn <br /> undisclosed_conflict ay_result ire the.terrrain�taan.Qf any grant awarded. <br /> Executive Director Dat <br /> Signature: - ..: �'�. � 17 -- -- <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/512017 12:58:45 PM <br />