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DocuSign Envelope ID:8A1AB1 BF-ACDB-42A1-A3DE-9E9549E569B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Farmer Foodshare <br /> Applicant Organization's Physical Address: 902 N. Mangum St, Durham, NC 27701 <br /> Applicant Organization's Mailing Address: P.O. Box 2873, Chapel Hill, NC 27515 <br /> Applicant Organization's Web Address: www.farmerfoodshare.orq <br /> Executive Director: Gini Bell <br /> Telephone Number: 919.360.6358 E-Mail: giniAfarmerfoodshare.or <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 Carrbor Chapel Oran a Total <br /> o Count <br /> Donation Station Program- Farmers Market $5,000 $5,000 $10,000 $20,000 <br /> based program that supports local Orange <br /> County farmers and organizations working <br /> to increase access to fresh food to <br /> community members in needs. <br /> Totals $5,000 $5,000 $10,000 1 $20,000 <br /> c) To the best of my knowledge and belief all information and data in this <br /> application is true and current. The document has been duly authorized by <br /> the governing board of the applicant. <br /> Signature: (ice- � L ' „ <br /> E I ;'cutive Director Date <br /> Signature. c 41' " 1 /3/// <br /> it — <br /> Board Ch erson r" Date <br /> Page 4 Of 20 <br />