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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Agency Voices Together <br /> Program(s) _Voices Together in Education <br /> 1. Cover Page a. ❑Applicant Contact Information <br /> b. El Funding Requests <br /> c. ❑Signed Application Cover Page <br /> d. ❑signed Disclosure of Conflicts of Interest and Clause <br /> e. <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 /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMII'age 6 ,r 31 <br />