Orange County NC Website
Browse       Search
Cover Page Page 8 of 37 <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 program <br />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, the Town <br />of Chapel Hill, or Orange County? <br /> <br /> 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 /> <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 <br />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 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, <br />handicap, religion, sexual orientation, gender identity/expression, familial status or veterans <br />status with reference to any activities carried out by the grantee, no matter how remote. The <br />parties hereto further agree in all respects to conform to the provision and intent of Orange <br />County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination <br />Policy. This provision is enforced by action for specific performance, injunctive relief, or <br />other remedy as by law provided; this provision shall be binding on the grantees, the <br />successors and assigns of the parties hereto with reference to the above subject manner. <br /> <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 /> <br /> <br />Signature: <br /> (Interim) Executive Director Date <br /> <br />Signature: <br /> Board Chairperson Date <br /> <br />1/13/2022 <br />01/13/2022 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: BC021861-30DF-4F8A-9FA3-8AE2B71D28D0