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DocuSign Envelope ID:4D553CF7-2BBD-4F4E-B84E-E6B8B077A9AB <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Freedom House Recovery Center <br /> Received By <br /> Program(s) Mental Health and Substance Use Date/Time <br /> Disorder Services <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> c. /t Signed Application Cover Page <br /> d. Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. ® Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. ® Agency's Types of Services Provided <br /> d. •1 Agency's Experience with Programs <br /> e. ® Other Pertinent Agency Information <br /> f. ® Schedule of Positions <br /> g. ® Living Wage <br /> h. 2 Agency Budget <br /> 3. Program Information a. ® Human Services Needs Priority <br /> b. I1 Type of Program <br /> A separate Section 3 is c. ® Agency Collaboration <br /> required for each program. d. ® Summary of Program <br /> e. ® Description of Identified Need <br /> f. ® Description of Population to be Served <br /> g. -1 Program Staffing, Capacity, & Expertise <br /> h. ® Program Implementation Timeline <br /> i. ® Value of Investment <br /> j. ® Impact of Reduced/No Allocation <br /> k. ® Other Pertinent Information <br /> I. /1 Target Population/Beneficiary Chart <br /> m. ® Work Statement <br /> n. ® Program Budget, Detail, &Cost per Individual <br /> Application Submittal Checklist 1/31/2017 11:17:39 AM Page 1 of 37 <br />