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DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Society for the Betterment of the Human Condition <br /> through the Training, Instruction and Propagation of Buda Karate (d.b.a. Ligo Dolo of Budo Karate) <br /> Applicant Organization's Physical Address: 630 Weaver Dairy Road Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: 2418 A Millwood Court Chapel Hill NC 27514 <br /> Applicant Organization's Web Address: <br /> Executive Director: Nathan Ligo <br /> Telephone Number: 919-923-6915 E-Mail: nligo a(7hotmail.com <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 Carrboro Chapel Orange Total <br /> -HS Hill L.HS County-HS <br /> Ex ;Youth Afterschool Program' $'10,000 $'15,000 $5000 $$0 000.:: <br /> Aftrschoel Program Coordinator salary and materials <br /> f©r youth:activities and:projects <br /> Young Warriors Program. Program Coordinator $4,000 $4,000 ;`. $4,000 $12,000 <br /> salary, program supplies, facility rent, and expenses. <br /> Totals $4,000 $4,000 $4,000 $12,000 <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 '; " P ) / ._ <br /> Executive-Dire?tor Date <br /> f=' <br /> i t f i <br /> Signature: # ; <br /> Board ohairperson Date <br /> AGENCY INFORMATION 1/31/2017 11:45:20 AM Page 1 of 2 0 <br />