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DocuSign Envelope ID:60192208-BFA3-4E38-9277-B2390FDDC97D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Behavioral Insights, Inc. <br /> Applicant Organization's Physical Address: 100 N. Churton Street, Suite 207, Hillsborough <br /> Applicant Organization's Mailing Address: 100 N. Churton Street, Suite 207, Hillsborough <br /> Applicant Organization's Web Address: www.behavioralinsightsorangenc.com <br /> Executive Director: Kathryn Bauman, LCSW <br /> Telephone Number (919) 391-0365 E-Mail: kathrygbaurnan@gmall corn <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 County-HS <br /> Ex.Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Programs to Fulfill Court and CPS $11,000 $35,000 $40,000 $86,000 <br /> Mandates <br /> Totals <br /> c) To the pest 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 irector Date <br /> Signature: <br /> J + , <br /> Board Chairperson Date 4' <br /> AGENCY INFORMATION 1/29/2017 9:40:56 PM Cage 3 of 21 <br />