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DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON- <br /> DISCRIMINATION CLAUSE <br /> Are any of the Board Members or employees of the organization which will be carrying out this project or their named <br /> project collaborators/partners or members of their immediate families,or their business associates... <br /> YES NO <br /> ❑ ❑ a)Employees of or closely related to employees of Orange County? <br /> ❑ ❑b)Members of or closely related to members of the governing bodies of Orange County? <br /> ❑ ❑ c)Current beneficiaries of the program for which funds are being requested? <br /> ❑ ❑ d)Paid providers of goods or services to the program or having other financial interest in the program? <br /> If you have answered YES to any question or know of any other potential conflict of interest regarding your application, <br /> please provide a full explanation here: <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for <br /> themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis <br /> of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, <br /> familial status or veterans status with reference to any activities carried out by the grantee, no matter how <br /> remote. The parties 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 provision is <br /> enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision <br /> shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above <br /> subject manner. <br /> To the best of my knowledge and belief all of the above information is true and current. I <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 /> Applicant's Authorized Signatory Date <br /> Page 7 of 17 <br />