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DocuSign Envelope ID:F9ADA870-944A-40DD-98D0-3DB55F3AD8E5 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Chapel Hill-Carrboro Public School Foundation <br /> Applicant Organization's Physical Address: 750 S. Merritt Mill Road, Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address: P. 0. Box 877, Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.publicschoolfoundation.orq <br /> Executive Director: Lynn Lehmann <br /> Telephone Number: 919-968-8819 E-Mail: Ilehmannchccs.k12.nc.us <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-HS <br /> Youth Afterschool Tutoring Program for Economically $840 $11,160 $0 $12,000 <br /> Disadvantaged Students Who Need Assistance in <br /> Reading and/or Mathematics <br /> Blue Ribbon Youth Leadership Institute $1,875 $4,500 $1,125 $7,500 <br /> Totals $2715 $15,660 $1,125 $19,500 <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 /> ,_ / - 3°- / 7 <br /> Signature: <br /> Executive Director Date <br /> SignaturLi/ IL <br /> - A ' (0-, <br /> or I - 30 -IT <br /> B•ard C airperson Date <br /> AGENCY INFORMATION 1/27/2017 10:33:14 AM Page * of 2 2 <br />