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DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 <br /> EXHIBIT A <br /> PROVIDERS OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Volunteers for Youth, Inc. <br /> Applicant Organization's Physical Address: 205 Lloyd Street, Suite 103, Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 205 Lloyd Street, Suite 103, Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.volunteersforvouth.orq <br /> Executive Director: Susan Worley <br /> Telephone Number: 919-9674511 E-Mail: Susan a(7valunteersforvouth.orq <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 /> Mentoring, community service, &teen court programs $3,000 $10,000 $10,000 $23,000 <br /> Portion of program coordinators' salaries, youth <br /> activities, and general operating expenses <br /> • <br /> Totals $3,000 $10,000 $10,000 $23,000 <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 /> Signature: G . -v7 <br /> E ecutive Director Date <br /> Signature: .i i. f <br /> l'7 <br /> Boar "• irperson Date <br /> 1:C� <br /> AGENCY INFOR *� •N 1211612016 1:33:44 PM Page 6 of 1 9 <br />