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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7
<br /> EXHIBIT A
<br /> PROVIDER'S OUTSIDE AGENCY APPLICATION
<br /> .- . ..,:. 1 CP1FER.PRGE; ;
<br /> a) Applicant Contact Information
<br /> Applicant Organization's Legal Name: The Exchange Club Center for the Prevention of Child d
<br /> Abuse of North Carolina, Inc/The Exchange Club's Family Center in Alamance County
<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 /> I
<br /> Executive Director: George Bryan. Interim/The Exchange Club Center for the Prevention of I
<br /> Child Abuse of North Carolina, Inc./Sarah Black/The Exchange Club's Family Center in Alamance g
<br /> County
<br /> Telephone Number: 336-748-9028/336-227-5601 E-Mail: george.bryan(r�exchangescan.orq/ Ii,
<br /> sarah.black( exchangescan.orq {
<br /> Tax [D Number:
<br /> b) Funding Request
<br /> List all FY17-1 8 Human Services (HS) Funding Being Requested--
<br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less)
<br /> • l
<br /> Program Carrboro Chapel -Orange: ' Total
<br /> ! HS, N l,, HiU HS County HS
<br /> ;3< - ,•yl- - -t .�, t l!1;j<j:'+�!I:�fil�;!�niS:'I!i ;�•I!sI'a!:ttlji!?ill!1, �;- .I•I:I t :!� ��: ! ',i! s t'' , !, _ @
<br /> i ESA Tooth Af rscl oo• rel opf p tE !•i; !!t 1{i :.t lilii!i�.Il:!I i ' -P i i$ 5 0 0=, $b V i 0 �0`
<br /> k,:......:.....: :.E>!},:t :4:,t1,lr;,,,„!>.1.:; I;•I,Iie.:,•:!,i€:;i}:I:its,I!,:E+1<I kk�,!i!:! I!• Ii43,e➢.: >E,t•I�, I, ,!u,t,.!t!,.I,• r:.,,�.,It,4l1,.!1!::..s'I!,: ,.;+,��,•!ril i.:r..._,..�:?.�
<br /> {� z.l.l t 1�,E.1l,.Itil.:.. l_I-]I:jl; JI lty.li E;.i t,,.1 kl.1!. ! ! •! i:};.,.i,...!..,!,tl:}L !t ! :I,=31.. :z•' ,
<br /> �fte: .gigO 13c i [X00,0�: i #; ;' c11 1!;IE!!�I1is!t•js 1 s..!!<'t.:ll�l'.11I;�!!i!I.€I{'(''u::I: ,tin 1 i t I Ij 1
<br /> !}��,'„ •s.:-��3 3,�,�s'�is�! Fl. .,,I:li :• .I!:�!; � ..r.:.�!I'I,n:{{.;j:. ;.11ljll!•t!- :I:- 1.-t i'.�:.€,i`i,lilu!:1:. >!'!-.x!u t sr i3s:cYr... '?' ;
<br /> .1;1.ill!.,Ott, .,-,.ulu itn Ikys;hr.: ..'.�� :.:. .4v3 ..T• i e •:1, �_ � :I It•:i�� i Ott. .!.•�•L:•!:!i4::3;: .9';
<br /> !!� !S'!..,..L. ..1.,3,<.L,i-t_,; ...! ..,ILt_,t.i-L. !� .#.•c<.!, ts.t. .�.,d: :I.n •I .1�11•,�. 's
<br /> �"jl%' #��IJ'141� ''P s•L .I II ilB l' .,.I!• !� }:IiS'j:; - .�;, :!i!:1 Ei.
<br /> 14t1 t li t! i. -1 i'i•w!t:,li l l..i=,!.11 sill,Ili,l.lti,III z•. s,,n'ta==: ;i1t;a;,!
<br /> a!; 5i ,! t '!: .p. .°.?!I!••,: ..II II : !,! Il 1 t !u,1,. .I. •!,. .is-..1.. ..- -• ..1t! Ii .'i:rl'.1'!`i.:,L.!..,..'!r�'.'i'r! 'tNaLi;^!d:,..........1,aieiS31!!'!1- 1
<br /> :.�4�:1�QUf�,.'e�li�l�{�1pSl'dl'1(�o,�1'Q���4�:4s.�:31IL!�:.i�:;�€Iji�€�,1;11�;t,El�,,l�l'•t!L•I:!.::,?a,fl!:6:!1,�11=;;k,?:s}1.�!�!!IEIS!:xlla:�rul,�;l:!tl!utett�h!I€ttli?+:::,;t=!-1 l- i-�';;:1-��E•�..:t. �!.. a:-i,. :.,,!..:1',
<br /> Parent Aide Program:salary and benefits of program $ O0QJ tl ct3 100 $13,'!00: • $28,200
<br /> staff, mileage, supplies/client emergency funds, I I F 1,3'k !”I!
<br /> rent/utilities/operations. ,W F il,l ! ,I , !
<br /> i il'i'1!x'-1:11!!. I I:
<br /> It?II I t ! !�'' !
<br /> iriMiliEagti flla.l.t3tir L. _......c... ..
<br /> ! iipi i
<br /> Totals
<br /> ,
<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: Y---- 2' 7'. J 7
<br /> Executive Director Date l
<br /> 7,7-11,,? /, . . , ,
<br /> Signature:
<br /> LA ) /JO-'196 fi 7 ,.
<br /> .:oafd Ch ir` ersen Date
<br /> AGENCY INFORMATION 1/27/2017 11:59:25 AM Page 2 of 1E,
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