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P a g e 3 o f 1 4 <br />DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON- <br />DISCRIMINATION CLAUSE <br />Are any of the Board Members or employees of the organization which will be carrying out this project or their named <br />project collaborators/partners 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 Orange County? <br /> <br />b) Members of or closely related to members of the governing bodies of Orange County? <br /> <br />X 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 in the program? <br /> <br />If you have answered YES to any question or know of any other potential conflict of interest regarding your application, <br />please provide a full explanation here: <br /> <br />As part of involving Club Nova members in all aspects of Club Nova, we have two m <br /> <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for <br />themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis <br />of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, <br />familial status or veterans status with reference to any activities carried out by the grantee, no matter how <br />remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County <br />Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is <br />enforced by action for specific 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 with reference to the above <br />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 />Applicant’s Authorized Signatory Date <br />DocuSign Envelope ID: A9B18E2F-7835-4086-B808-E21D1F44AE18