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DocuSign Envelope ID: E865EBC7-DCBB-4CE6-A224-13D663E29E12 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Women's Center, Inc. dba Compass Center <br /> for Women and Families <br /> Applicant Organization's Physical Address: 210 Henderson St, Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: Post Office Box 1057 Clip"lei Hill NC 27514 <br /> Applicant Organization's Web Address: compassctr.orq <br /> Executive Director: Corclelia Heaney <br /> Telephone Number:1219) 968-4610 E-Mail: directon@cornpassctr.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 /> Ex.Youth Afterschool Program $1.0,000 $15,000 $5,000 <br /> Program Coordinator salary and materials <br /> for youth activities and projects <br /> To provide domestic violence crisis services, financial $9,000 $30,300 $65,900 $105,200 <br /> education and career preparedness services, legal <br /> information services, connections to community <br /> resources, youth and adult training and education on <br /> the prevention of interpersonal violence and civic <br /> d to and gender issues <br /> engagement relat...e o women's�.� .... m.. �, ,„... ......._ �... �� , <br /> Totals $9,000 $30,300 $65,900 $105,200 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: <br /> Executive Director Date <br /> Signature: � �, 'r��.,. ':. zr ( °I �� . <br /> Bar Chairperson Date <br /> 4 rvf w <br /> AGENCY INFORMATION 1/30/2017 4:02:21 PM Page 7 o f 4 8 <br />