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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Exchange Club Center for the Prevention of Child Abuse <br /> of North Carolina, Inc's The Exchange Club's Family Center in Alamance <br /> Applicant Organization's Physical Address: 200 N. Main Street Graham, NC 27253 <br /> Applicant Organization's Mailing Address: 200 N. Main Street Graham, NC 27253 <br /> Applicant Organization's Web Address: www.exchangescan.orq <br /> Executive Director: Cynthia Napoleon-Hanger <br /> Telephone Number: 336-748-9028 E-Mail: Cynthia.hangerAexchangescan.org <br /> DUNS Number: 171570203 <br /> (Dun&Bradstreet, Inc. provides this number at no charge,and it is required for Federal funding recipients.) <br /> b) Project/Program Contact Information <br /> Project/Program Name: Parent Aide Services <br /> Project/Program Primary Contact and Title: Sarah Black, County Director <br /> Telephone Number: 336-227-5601 E-Mail: sarah.black@exchangesgan.orq <br /> c) Funding Request Identification <br /> Total Project/Program Cost $4?, Total Amount of Funds Requested: $23,700 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funds will be expended on the provision <br /> of Parent Aide services in Orange County. <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source. *The Participating Jurisdiction reserves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> El CDBG Non-Construction (CH) $ A Grant EA Loan <br /> El CDBG Construction (CH) ED Grant El Loan <br /> HOME CHDO (OC) 0 Grant El Loan <br /> El HOME Other(OC) Grant 0 Loan <br /> Human Services: i1 Carrboro $3000 4 Chapel Hill $10,350 i4 Orange County$10,350 <br /> d) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Ogfr' <br /> Signature: AD, LAIL. r <br /> ecutive Dir;cto, - Date <br /> Signature d /di„ if ... <br /> era r• A,:rpe on Date <br /> Main Appliation 1/21/2016 12:08:06 PM Page 3 of 3 <br />