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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency Orange County Living Wage Received By <br /> Program(s) Certification Program Date/Time / <br /> «RRRRR��RRRRRRRRRRRRRRRRRRR�RRRRRRRRRRRRRRRRRRRR��RRRRRRRRRRRRRRRRRRR��RRRRRRRRRRRRRRRRRRR�RRRRRRRRRRRRRRRRRRRR��RRRRRRRRRRRRRRRRRRR��RRRRRRRRRR�� <br /> Section Subsection <br /> a. ❑Applicant Contact Information <br /> 1. Cover Page <br /> b. ❑ Funding Requests <br /> c. ❑ Signed Application Cover Page <br /> d. ❑Signed Disclosure of Conflicts of Interest and Clause <br /> e. <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. ❑Agency's Experience with Programs <br /> e. ❑ Other Pertinent Agency Information <br /> f. ❑ Schedule of Positions <br /> g. ❑ Living Wage <br /> h. ❑Agency Budget <br /> 3. Program Information a. ❑ Human Services Needs Priority <br /> b. ❑ Type of Program <br /> A separate Section 3 is c. ❑Agency Collaboration <br /> required for each program. <br /> d. ❑ Summary of Program <br /> e. ❑ Description of Identified Need <br /> f. ❑ Description of Population to be Served <br /> g. ❑ 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. ❑ Target Population/Beneficiary Chart <br /> m. ❑Work Statement <br /> n. ❑ Program Budget, Detail, &Cost per Individual <br /> DO NOT SUBMIT THIS PAGE 12/15/2016 9:57:17 AMII'age 6 •r 32 <br />