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Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency The Arc of the Triangle, Inc. Date/Time / <br /> Complete Y <br /> Program(s) Social and Volunteer Programs <br /> Section . : ā€¢ <br /> . Regulations <br /> 1. Cover Page a. x Applicant.Contact Information <br /> b. x Project/Program Contact Information <br /> c. x Funding Requests Identified <br /> d. ā‘ Signed Application Cover Page <br /> 2. Agency a. x Agency's Years in operation 24 CFR 570.506, <br /> Information - b. x Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. x Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. x Agency's Experience <br /> e. x Other Pertinent Information <br /> 3. Program/ a. x Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. x Summary of Program 570.201-570. 208, <br /> Information - c. x Description of Identified Need 507.503 <br /> (for each d. x Description of Population to be Served <br /> program/ <br /> project for e. x Activity Manager and Location Description <br /> which funding f. x Activity Implementation Timeline <br /> is requested) gā€¢ x Agency Collaboration <br /> h. x Describe Impact of Reduced/No Allocation <br /> i. x Other Pertinent Information <br /> j. x Complete Target Population/Beneficiary Chart <br /> k. x Complete Schedule of Positions <br /> I. ā‘ Signed Conflict of Interest Disclosure <br /> m. x Complete Work Statement <br /> i Page <br />