Orange County NC Website
Browse       Search
DocuSign Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> The Historic Hillsborough Commission <br /> Received By <br /> Visitor Services at: Date/Time <br /> The Burwell School Historic Site <br /> Section Subsection <br /> 1. Cover Page a. Applicant Contact Information <br /> b. A, Funding Requests <br /> C. Ul Signed Application Cover Page <br /> d. 71Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. 2)Agency's Years in operation <br /> b. 0Agency's Purpose/Mission <br /> c. Da:Agency's Types of Services Provided <br /> d. [atAgency's Experience with Programs <br /> e. f Other Pertinent Agency Information <br /> f. 1M Schedule of Positions <br /> g. I! Living Wage <br /> h. li:i,Agency Budget <br /> 3. Program Information a. 4E1 Human Services Needs Priority <br /> b. SI,Type of Program <br /> A separate Section 3 is c. 'Agency Collaboration <br /> required for each program. d. Summary of Program <br /> e. es c ript ion of identified Need <br /> f. sescription of Population to be Served <br /> g. eProgram Staffing, Capacity, & Expertise <br /> Program Implementation Timeline <br /> i. --0Value of Investment <br /> j.,./Ne Impact of Reduced/No Allocation <br /> k.)jal Other Pertinent Information <br /> 1. r Target Population/Beneficiary Chart <br /> m.,Ia Work Statement <br /> n. g.Program :udget, Detail, &Cost per Individual <br /> 4. Attachments a. Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance, and/or organizations with more than $500,000 <br /> of receipts and expenditures in a fiscal year, must secure an audit. <br /> b. MI IRS Federal Form 990 <br /> C. C Solicitation License <br /> d. J Federal Tax-Exemption Letter <br /> e. ertificate of Insurance <br /> f. 11!s, ist of Board of Directors <br /> g Ike.lid Waste Program Fee (SWPF)Verification <br /> Application Submittal Checklist 1/31/2017 4:15:48 PM r f 2 ? <br />