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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Agency Boys & Girls clubs of Durham and Orange Counties <br /> Program(s) Chapel Hill Program for Impact <br /> Section Subsection <br /> 1. Cover Page a. ®Applicant Contact Information <br /> b. Funding Requests <br /> c. 11 Signed Application Cover Page <br /> d. /'1Si s ned 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. /1 Agency's Types of Services Provided <br /> d. ®Agency's Experience with Programs <br /> e. /1 Other Pertinent Agency Information <br /> f. Schedule of Positions <br /> g. /1 Living Wage <br /> 3. Program Information a. ® Human Services Needs Priority <br /> b. ® Type of Program <br /> A separate Section 3 is c. I1 Agency Collaboration <br /> required for each program. <br /> d. ®Summary of Program <br /> e. 1/ Description of Identified Need <br /> f. /1 Description of Population to be Served <br /> g. ►„1 Program Staffing, Capacity, &Expertise <br /> h. /:1 Program Implementation Timeline <br /> i. /,;1 Value of Investment <br /> j. `1 impact of Reduced/No Allocation <br /> k. Other Pertinent Information <br /> 1. Target PopulationlBeneflciary Chart <br /> m. /`1 Work Statement <br /> 4. Attachments a. /1 Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance, and/or organizations with more than$500,000 of <br /> receipts and expenditures in a fiscal year, must secure an audit. <br /> b. ►1 IRS Federal Form 990 <br /> c. /1 NC Solicitation License <br /> d. IRS Federal Tax-Exemption Letter <br /> e. 11 Certificate of Insurance <br /> f. F1 List of Board of Directors <br />