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DocuSign Envelope ID:6D821DA0-CO6F-4D38-BB4F-DB28CB54AD8E XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: OE Enterprises, Inc. <br /> Applicant Organization's Physical Address: 348 Elizabeth Brady Rd. <br /> Hillsborough, NC 27278 <br /> Applicant Organization's Mailing Address: 348 Elizabeth Brady Rd. <br /> Hillsborough, NC 27278 <br /> Applicant Organization's Web Address: www.oeenterprises.org <br /> Executive Director: Margaret Samuels <br /> Telephone Number: 919-732-8124 E-Mail: samuelsm@oeenterprises.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 /> Proqram Carrboro Chapel Oranqe Total <br /> - HS Hill - HS County-HS <br /> Transitions to Employment $5,000 $12,000 $58,000 $75,000 <br /> Proposed use of funds: Personnel costs <br /> associate with providing vocational <br /> placement, training, and community <br /> integration supports for students and <br /> adults who have disabilities. <br /> Totals $5,000 $12,000 $58,000 $75,000 <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 <br /> the applicant. <br /> Signature: a < <._,, ;,� 1/28/17 <br /> Exec if Director Date <br /> r� <br /> Signature: "�.Jov., - (,t 1. 1/28/17 <br /> Board Chairpers c Date <br /> Agency Information 1/31/2017 8:24:51 AM ll ' ago 3 of 20 <br />