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DocuSign Envelope ID: 1A43D806-0D44-4AC1-898C-3042FDBCA241 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Child Care Services Association <br /> Applicant Organization's Physical Address: 1829 E. Franklin St. Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: PO Box 901, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www.childcareservices.org <br /> Executive Director: Anna Carter <br /> Telephone Number: 919-967-3272 E-Mail: annacAchildcareservices.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County- <br /> , <br /> HS <br /> CCSA Child Care Scholarship Program $7,500 $12,500 $35,000 $55,000 <br /> Child care financial assistance to children in <br /> lower-income families engaged in work, school, <br /> or trainin. related activities <br /> Totals $7,500 $12,500 $35,000 $55,000 <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 /> , <br /> CO; <br /> Executive Director Date <br /> 41 • <br /> Signature: • 4 -1 <br /> Board AT. Date -- <br /> AGENCY INFORMATION 1/27/2017 8:51:47 AM P q e 2 of <br />