Orange County NC Website
Browse       Search
DocuSign Envelope ID:6D821DA0-CO6F-4D38-BB4F-DB28CB54AD8E XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency OE Enterprises, Inc. Received By <br /> Date/Time <br /> Program(s) Transitions to Employment <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> c. ® Signed Application Cover Page <br /> d. Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. ® Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. ® Agency's Types of Services Provided <br /> d. ® Agency's Experience with Programs <br /> e. ® Other Pertinent Agency Information <br /> f. ® Schedule of Positions <br /> g. ® Living Wage <br /> h. ® Agency Budget <br /> 3. Program Information a. ® Human Services Needs Priority <br /> b. ® Type of Program <br /> A separate Section 3 is c. ® Agency Collaboration <br /> required for each program. d. ® Summary of Program <br /> e. ® Description of Identified Need <br /> f. ® Description of Population to be Served <br /> g. ® Program Staffing, Capacity, & Expertise <br /> h. ® Program Implementation Timeline <br /> i. ® Value of Investment <br /> j. ® Impact of Reduced/No Allocation <br /> k. ® Other Pertinent Information <br /> I. ® Target Population/Beneficiary Chart <br /> m. ® Work Statement <br /> n. ® Program Budget, Detail, & Cost per Individual <br /> Application Submittal Checklist 1/31/2017 8:24:51 AM Pago I of 20 <br />