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DocuSign Envelope ID: 5F353138-C664-4703-97A3-A28BCE0500B7 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Boomerang Youth, Inc. <br /> Applicant Organization's Physical Address: 825A N. Estes Drive,Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: 825A N. Estes Drive Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: boomerangyouth.orq <br /> Executive Director: Tami Pfeifer <br /> Telephone Number: (919) 968-2146 E-Mail: tamipfeiferAboomerandyouth.org <br /> Tax ID Number: <br /> b) Funding Request <br /> Program Carrboro -HS Chapel Hifi-HS Orange County-HS Total] <br /> Program Manager(s)salary 3,900 7,800 11,700 23,400 <br /> Psycho-educational skill building 0 1,750 1,750 3,500 <br /> groups:. conflict resolution, healthy <br /> relations„ substance use, 1 <br /> communication and self-expression, <br /> personal growth (contractors) 1 1 <br /> Materials for after school community 0 450 0 450 <br /> service/service learning projects <br /> Totals 3,900 10,000 13,460 27,350 <br /> c) 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 /> Signature: <br /> T i Pfeifer, Executi ir- or <br /> la <br /> '.i 1 Di te <br /> li <br /> I ' ':2)C - I ''''t <br /> Signaturell: -''' _ ',,,) 2 ,/ ,„2,; ', ,ti--',...,___ <br /> Isabel Geffn-r, Boa d ,g jlla i r p e r s o n Date <br />