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AGENCY INFORMATION 8/31/2018 11:35:08 AM Page 2 of 11 <br />d)DISCLOSURE OF POTENTIAL CONFLICTS OF INTERESTAND NON DISCRIMINATION <br />CLAUSE <br />Are any of the Board Members or employees of the agency which will becarrying out this program or <br />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, orOrange County? <br />b)Members of or closely related to members of the governing bodies of the Town of Carrboro, <br />the Town of Chapel Hill, orOrange County? <br />c)Current beneficiaries of the program for which funds arebeingrequested? <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, 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 current. <br />I acknowledge and understand that the existence of a potential conflict of interest does not <br />necessarily make the programineligible for funding, but the existence of an undisclosed <br />conflict may result in the termination of any grant awarded. <br />Signature: <br />Executive DirectorDate <br />Signature: <br />Board ChairpersonDate <br /> <br /> <br />Exhibit A <br />Provider's Cardinal Managed Care Application and Work Statement <br />DocuSign Envelope ID: 45F8D9E2-21AC-4868-9A00-7CEFD1517F11