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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency The Women's Center, Inc. dba Compass <br /> Center for Women and Families Received By <br /> Date/Time <br /> Program(s) Domestic Violence Crisis Services, IIMAGYASAMMONOMMINAIM WOMMOKKONNUMDINOWN WOW 66WOM AINIM66 AMMINANOWV <br /> Self-Sufficienc Pro!rams Comrnunit <br /> Education and Civic Enuagetrient <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> c. ® 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. ® 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, 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 /> Application Submittal Checklist 1/30/2017 4:02:21 PM l' a g o o . <br />