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DocuSign Envelope ID: E9553E7D-3748-4C37-A9D7-602D42934ACC Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Received By <br /> Agency _Public_Gallery of Carrboro dba WCOM, Date/Time / 1 <br /> Complete Y/N <br /> Program(s) _Community Radio <br /> Section Subsection For CDBG & HOME - <br /> HUD Regulations <br /> 1. Cover Page a. XX❑ Applicant Contact Information <br /> b. XX❑ Project/Program Contact Information <br /> c. XX❑ Funding Requests Identified <br /> d. XX❑ Signed Application Cover Page <br /> 2. Agency a. XX❑ Agency's Years in operation 24 CFR 570.506, <br /> Information - b. XX❑ Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. )0(1-1 Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. )Xn Agency's Experience <br /> e. XXn Other Pertinent Information <br /> 3. Program/ a. XX❑ Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. 570.201-570. 208, <br /> XX❑ Summary of Program <br /> Information - c. )0411 Description of Identified Need 507.503 <br /> (for each d. )Xn Description of Population to be Served <br /> program/ <br /> project for e. )0411 Activity Manager and Location Description <br /> which funding f. XX❑ Activity Implementation Timeline <br /> is requested) g. )0411 Agency Collaboration <br /> h. XX❑ Describe Impact of Reduced/No Allocation <br /> i. XX❑ Other Pertinent Information <br /> j. XX❑ Complete Target Population/Beneficiary Chart <br /> k. XX❑ Complete Schedule of Positions <br /> I. XXn Signed Conflict of Interest Disclosure <br /> m. XXn Complete Work Statement <br /> i o:° <br />