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Cover Page P a g e 11 o f 55 <br /> <br />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 /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of the Town of Carrboro, <br />the Town of Chapel Hill, or Orange County? <br /> <br /> b) Members of or closely related to members of the governing bodies of the <br />Town of Carrboro, the Town of Chapel Hill, or Orange County? <br /> <br /> c) Current beneficiaries of the program for which funds are being requested? <br />Two Club Nova members serve on the Club Nova Community, Inc. Board of <br />Directors. <br /> <br /> d) Paid providers of goods or services to the program or having other financial <br />interest in the 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 <br />to the parties hereto for themselves, their agents, officials, employees and servants <br />agree not to discriminate in any manner of these basis of race, color, gender, <br />national origin, age, handicap, religion, sexual orientation, gender <br />identity/expression, familial status or veterans status with reference to any activities <br />carried out by the grantee, no matter how remote. The parties hereto further agree <br />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 <br />provision is enforced by action for specific performance, injunctive relief, or other <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614