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DocuSign Envelope ID:2A83AE93-E43A-4DCA-8002-FA0D789204A6 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency: Big Brothers Big Sisters <br /> I <br /> of the Triangle, Inc. Received By <br /> Date/Time <br /> Program(s): Community and <br /> School-Based Mentoring <br /> 1. Cover Page a. El Applicant Contact Information <br /> b. El Funding Requests <br /> C. El Signed Application Cover Page <br /> d. illiSigned Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. El Agency's Years in operation <br /> b. E] Agency's Purpose/Mission <br /> c. E] Agency's Types of Services Provided <br /> d. El Agency's Experience with Programs <br /> e. El Other Pertinent Agency Information <br /> f. El Schedule of Positions <br /> g. El Living Wage <br /> h. [I] Agency Budget <br /> 3. Program Information a. El Human Services Needs Priority <br /> b. ID Type of Program <br /> A separate Section 3 is c. (11 Agency Collaboration <br /> required for each program. d. El Summary of Program <br /> e. El Description of Identified Need <br /> f. El Description of Population to be Served <br /> g. El Program Staffing, Capacity, & Expertise <br /> h. El Program Implementation Timeline <br /> i. [1] Value of Investment <br /> j. El Impact of Reduced/No Allocation <br /> k. El Other Pertinent Information <br /> I. El Target Population/Beneficiary Chart <br /> m. 1:1 Work Statement <br /> n. El Program Budget, Detail, &Cost per Individual <br /> Application Submittal Checklist 1/27/2017 1:43:18 PM Page 5 of 24 <br />