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DocuSign Envelope ID: 1632E805-38D3-49DF-9836-981006B20F64 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Historic Hillsborough Commission, Inc. <br /> Applicant Organization's Physical Address: 319 N Churton Street Hillsborough, NC 27278 <br /> Applicant Organization's Mailing Address: PO Box 922 Hillsborough, NC 27278 <br /> Applicant Organization's Web Address: vvvvvv.burvvellschool.or• <br /> Executive Director: Kate Fahert Telephone Number: 9197327451 <br /> E-Mail: directorRburwellschool.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 <br /> The HCC proposes to strengthen & expand visitor services at the Burwell School <br /> Historic Site, providing historical and cultural service for Orange County residents <br /> and visitors from all parts of the state and beyond. Three major components <br /> 1. Program planning and 5,000 <br /> implementation <br /> 2. Site maintenance and restoration 4,000 <br /> of deteriorating materials <br /> 3. Year-long observance of the life of 1,000 <br /> Elizabeth Hobbs Keckly, <br /> bicentennial year 2018, with <br /> educational programming and <br /> expanded exhibit. <br /> Totals for all 3 Programs listed above $10,000 <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: <br /> Executive Direc r Date <br /> Signature: I IPA" 1 e <br /> —3 1 <br /> Board Chairpers1.1 Date <br /> AGENCY INFORMATION 1/31/2017 4:15:48 PM q c, 6 oi t 7 <br />