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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 <br />this 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, <br />the Town of Chapel Hill, or Orange County? <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 />☐ ☒c) Current beneficiaries of the program for which funds are being <br />requested? <br />☐ ☒d) Paid providers of goods or services to the program or having other <br />financial 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 <br />agencies to the parties hereto for themselves, their agents, officials, employees <br />and servants agree not to discriminate in any manner of these basis of race, color, <br />gender, national origin, age, handicap, religion, sexual orientation, gender <br />identity/expression, familial status or veterans status with reference to any <br />activities carried out by the grantee, no matter how remote. The parties hereto <br />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 <br />Anti-discrimination Policy. This provision is enforced by action for specific <br />performance, injunctive relief, or other remedy as by law provided; this provision <br />shall be binding on the grantees, the successors and assigns of the parties hereto <br />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 />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: 33DAB98C-9F47-479D-8E75-67FFA543C9FB