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DocuSign Envelope ID: B55679E1-82FB-4A06-BBCF-6BC218E4CADA Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency _Piedmont Wildlife Center Date/Time <br /> Complete Y/N <br /> Program(s)_Nature Day Camp <br /> Subsection For CDBG & HOME - <br /> Section HUD Regulations <br /> 1. Cover Page a. Applicant Contact Information <br /> b. Project/Program Contact Information <br /> c. Funding Requests Identified <br /> d. Signed Application Cover Page <br /> 2. Agency a. Agency's Years in operation 24 CFR 570.506, <br /> Information - b. Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. Agency's Experience <br /> e. Other Pertinent Information <br /> 3. Program/ a. Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. Summary of Program 570.201-570. 208, <br /> Information 507.503 <br /> c. Description of Identified Need <br /> d. Description of Population to be Served <br /> (for each <br /> e. Activity Manager and Location Description <br /> program/ <br /> project for f. Activity Implementation Timeline <br /> which g. Agency Collaboration <br /> funding is h. Describe Impact of Reduced/No Allocation <br /> requested) i. Other Pertinent Information <br /> j. Complete Target Population/Beneficiary Chart <br /> k. Complete Schedule of Positions <br /> I. Signed Conflict of Interest Disclosure <br /> a. Complete Work Statement <br /> 1 o:���` <br />