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DocuSign Envelope ID:2A83AE93-E43A-4DCA-8002-FA0D789204A6 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Big Brothers Big Sisters of the Triangle, Inc. <br /> Applicant Organization's Physical Address: 808 Aviation Parkway, Suite 900 Morrisville, NC <br /> 27560 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.bbbstriangle.org <br /> Executive Director: Kim Breeden <br /> Telephone Number: 919-850-9772 E-Mail: kbreeden(@,bbbstri.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 County-HS_ <br /> We are requesting funds to continue to support our $5,000 $10,000 $10,000 $25,000 <br /> Community and School-Based Mentoring Programs in <br /> Carrboro, Chapel Hill, and all of Orange County for at- <br /> risk children ages six to 14. <br /> Totals $5,000 $10,000 $10,000 - $25,000 <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 /> )t) <br /> Signature -7` 1/27/17 <br /> Executiv Directo Date <br /> Signature: /‘1,4 1/27/17 <br /> Board C 'rpers Date <br /> AGENCY INFORMATION 1/26/2017 9:39:14 AM Page 7 of 23 <br />