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DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND <br />NON-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 />YES NO <br />☐ ☒a) Employees of or closely related to employees of the Town of Carrboro, the <br />Town of Chapel Hill, or Orange County? <br />☐ ☒b) Members of or closely related to members of the governing bodies of the Town <br />of Carrboro, the Town of Chapel Hill, or 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 <br />interest in the 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 <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, national <br />origin, age, handicap, religion, sexual orientation, gender identity/expression, familial <br />status or veterans status with reference to any activities carried out by the grantee, no <br />matter how remote. The parties hereto further agree in all respects to conform to the <br />provision and intent of Orange County Civil Rights Ordinance, as amended and the <br />Orange County Anti-discrimination Policy. This provision is enforced by action for <br />specific performance, injunctive relief, or other remedy as by law provided; this <br />provision shall be binding on the grantees, the successors and assigns of the parties <br />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 <br />interest does not necessarily make the program ineligible for funding, but the <br />existence of an undisclosed conflict may result in the termination of any grant <br />awarded. <br />Signature: <br />Executive Director Date <br />Signature: <br />Board Chairperson Date <br />Cover Page Page 3 of 10 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 70AC09D8-3205-4A8F-BDE0-893B802CD27D