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DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON-DISCRIMINATION <br /> 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 /> YES NO <br /> ❑ ip a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> ❑ 'F!i 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 /> ❑ in 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 <br /> 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 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 identitylex press ion, 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 /> 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 /> Ex cutave Direct r Date <br /> Signature: 44 /// <br /> Boar airpirsotf Date <br /> ApRlication Signatures: Please submit a wet signature or electronic signature, MS Word <br /> cursive fonts are not acceptable. A <br /> Program information Page 11 of 30 <br />