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d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON <br />DISCRIMINATION CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out this <br />program or members of their immediate families, or their business associates… <br />YESNO <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 <br />Carrboro, the Town of Chapel Hill, or Orange County? <br /> <br />☐ ⛝ c) Current beneficiaries of the program for which funds are being requested? <br /> <br />☐ ⛝ d) Paid providers of goods or services to the program or having other financial interest <br />in 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 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 <br />current. I acknowledge and understand that the existence of a potential conflict of <br />interest does not necessarily make the program ineligible for funding, but the existence <br />of an undisclosed conflict may result in the termination of any grant awarded. <br />Signature: 1/12/18 <br /> President & CEO Date <br />Signature: 1/19/18 <br /> Board Chairperson Date <br />Exhibit A: Provider's Outside Agency Application <br />DocuSign Envelope ID: ED368FB6-6FB1-45A7-A8CA-9AB3EAEB624E