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DocuSign Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> # of FTE - Full-Time Paid Positions: 0 <br /> # of FTE - Paid Part-Time Positions: 2 PT positions, (total of I FTE) <br /> # of Volunteers:42 # of FTE - Volunteers: 1.2 <br /> • Living Wage: Does this agency pay permanent employees a minimum living wage? <br /> (Yes/No) Yes <br /> If yes, is this agency an Orange County Living Wage Certified Employer? Yes <br /> • Agency Budget <br /> i. Is your agency currently receiving and/or requesting other (non-Human Services) <br /> local (Town of Carrboro, Town of Chapel Hill, Orange County) government <br /> funding? (Yes/No) Yes <br /> If yes, please fist below: <br /> Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hilt <br /> and Orange County governments (other than Human Services). DO NOT include federal <br /> funding sources, such as CDBG and HOME. <br /> Program FY16-17 FY17-18 Source <br /> Award Reqqest <br /> Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing <br /> Rehabilitation <br /> Ex: Agency Administration $15,000 $15,000 Carrboro - Other <br /> Ex. Total $15,000 $35,000 Carrboro Total Funding <br /> ( <br /> The Burwell School Historic 8857 10,000 Orange County Human Services <br /> Site Visitor Services <br /> • Program planning 5,000 <br /> and support <br /> • Site Operations 4,000 <br /> • Elizabeth 1000 <br /> Bicentennial <br /> program planning <br /> *Add rows or attach additional page, if needed. <br /> Agency Information 1/31/2017 4:15:48 PM P 'aqe 9 of 22 <br />