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DocuSign Envelope ID: 1BB65AEA-3E6A-45BE-8A7F-19FFOF9A712A <br /> EXHIBIT A: 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 agency which will be carrying out this program or <br /> members of their immediate families, or their business associates... <br /> YES NO <br /> ❑ o a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> ❑ o 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 /> ❑ o c) Current beneficiaries of the program for which funds are being requested? <br /> ❑ o d) Paid providers of goods or services to the program or having other financial interest in the <br /> 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 <br /> hereto further agree in all respects to conform to the provision and intent of Orange County <br /> Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This <br /> provision is enforced by action for specific performance, injunctive relief, or other remedy as by <br /> law 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 interest <br /> does not necessarily make the program ineligible for funding, but the existence of an <br /> undisclosed conflict may result in the termination of any„grant awarded. <br /> Signature: <br /> Executive Directto�rJ� �_ Date 1/22/18 <br /> g <br /> Si nature: <br /> Board Chairperson Date 1/22/18 <br />