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DocuSign Envelope ID: 571863E8-F892-43F0-B73F-4AB062ACBOBF XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Voices Together <br /> Applicant Organization's Physical Address: 5007 Southpark Dr., Ste. 230, Durham, NC <br /> 27713 <br /> Applicant Organization's Mailing Address: 5007 Southpark Dr., Ste. 230, Durham, NC <br /> 27713 <br /> Applicant Organization's Web Address: www.voicestogether.net <br /> Executive Director: Yasmine White <br /> Telephone Number: 919-942-2714 E-Mail: yasmine(cvoicestogether.net <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 Carrbo Chapel Orange Total <br /> ro - HS Hill - County- <br /> HS HS <br /> Ex. Youth Afterschool Program $10,00 $15,00 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and 0 0 <br /> materials for youth activities and projects <br /> VT in Education program in four Orange $20,000 $20,000 <br /> County exceptional children's classrooms for <br /> Music Therapist salary and materials <br /> Totals <br /> DO NOT SUBMIT THIS PAGE 1/26/2017 11:10:15 AMIII'age 8 •t 31 <br />