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DocuSign Envelope ID: B67A2C26-3304-4095-BB1C-73A2BC4A569A <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Habitat for Humanity of Orange County <br /> Applicant Organization's Physical Address: 88 Vilcom Center Dr. #L110, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 88 Vilcom Center Dr. #L110, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www.orangehabitat.org <br /> Executive Director: Susan Levy <br /> Telephone Number: (919) 932-7077 ext. 211 E-Mail: slevy @orangehabitat.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 Countv-HS <br /> Home Preservation $0 $0 $50,000 $50,000 <br /> Totals $0 $0 $50,000 $50,000 <br /> c) To the best of my knowledge and belief all information and data in this application is true <br /> and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: 1/31/2017 <br /> Executive Director Date <br /> Signature: Gam- ! 1/31/2017 <br /> Board Chairperson Date <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br /> CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this program or <br /> members of their immediate families, or their business associates... <br /> YES NO <br /> ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> ❑ ® b) Members of or closely related to members of the governing bodies of the Town of <br /> Carrboro, the Town of Chapel Hill, or Orange County? <br /> DO NOT SUBMIT THIS PAGE 1/31/2017 2:31 :06 PM Page 6 of 1 <br />