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XI. CERTIFICATIONS <br />A. Applicant certifies that it will not discriminate against any employee or applicant for employment because of race, <br />religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital <br />status, sex or age, in compliance with Government Code 12900, at seq. Applicant agrees to take affirmative <br />action to insure that applicants are employed, and that employees are treated during employment, without regard <br />to their race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical <br />condition, marital status, sex or age. <br />B. Applicant certifies that it does not discriminate against any person wishing to benefit from their services /program <br />on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical <br />condition, marital status, sex or age. <br />C. Does any officer, employee or board member have an ownership interest, either directly or through a partnership <br />or corporate entity, in any facilities owned, leased, or rented by the applicant organization? This includes leases <br />between an organization and a director, trustee, officer or key employee of the organization or his /her immediate <br />family either directly or through corporations, trusts, or similar arrangements in which they hold a controlling <br />interest. ❑ Yes ❑ No <br />If Yes, please list the individual(s) and /or company(ies) below. <br />Name <br />D. Do your board members receive a salary or other stipend for serving on this board? <br />❑ Yes ❑ No (If yes, include amount next to each board member's name as part of attachment #5) <br />E. What was the date of the last meeting of your board of directors? <br />XII. SIGNATURE <br />I hereby certify that, to the best of my knowledge, all statements made in this application are true and correct. If funds are <br />granted to our organization, they will be used for a ESG- eligible purpose. I understand that liability and workers <br />compensation insurance will be required for our group, and that our formal agreement with the City will specify other <br />reporting and programmatic provisions. <br />Name Title <br />Signature Date <br />11 <br />19D -14 <br />