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Cover Page Page 3 of 11 <br /> <br />DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON-DISCRIMINATION 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 /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, <br />or Orange County? <br /> <br /> b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the <br />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 in the <br />program? <br />If you have answered YES to any question, please provide a full explanation below. <br /> <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br />hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any <br />manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, <br />gender identity/expression, familial status or veterans status with reference to any activities carried out <br />by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to <br />the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County <br />Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive <br />relief, or other 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 current. I <br />acknowledge and understand that the existence of a potential conflict of interest does not necessarily <br />make the program ineligible for funding, but the existence of an undisclosed conflict may result in the <br />termination of any grant awarded. <br /> <br /> <br />Signature: January 13, 2021 <br /> Executive Director Date <br /> <br />Signature: January 13, 2021 <br /> Board Chairperson Date <br /> <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 632D5DCD-C75A-47B6-A24A-296BD1CD5165