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DocuSign Envelope ID: FCA96EA6-6080-4E8E-8EFF-B03ECA597827 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Boys & Girls Clubs of Greater Durham, soon to be Boys <br /> & Girls Clubs of Durham and Orange Counties (in the process of making this legal change) <br /> Applicant Organization's Physical Address: 808 East Pettigrew Street, Durham, NC 27701 <br /> Applicant Organization's Mailing Address: PO Box 446, Durham, NC 27702 <br /> Applicant Organization's Web Address: www.durhambgc.org <br /> Executive Director: Jerome Levisy <br /> Telephone Number: 919-687-4517,X20 E-Mail:jlevisy©durhambgc.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-118 Human Services (HS) Funding Being Requested– <br /> For All Proorams) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Hill Orange ' Total <br /> H$ HS County- <br /> H; <br /> yr,/ 05.00f .10M/#“000,0 00.6 00u00mmurfarn <br /> The BGCDOC Community Impact Program in $10,000 $10,000.00 $10,000.00 $30,000.00 <br /> Chapel Hill. <br /> Funds for salaries and benefits for the full time <br /> Program Director,two part-time program <br /> assistants who provide program services to the <br /> youth In the program. <br /> 111.1111. <br /> rnr rnr. rnr. rnr n mvhr.Av.,/07.1.01 1, 4/ <br /> 01,00,. r <br /> mnemrr <br /> Totals $10,000.0 $10,000.00 $10,000.00 $30,000.00 <br /> 0 <br /> c) To the best of my knowledge and belief all information and data in this application is true <br /> and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: <br /> Ex utive Director Date <br /> / <br /> 041111roP <br /> Signature: 1 ' i/27//i- <br /> Board Chairperson 44f) Date <br /> AGENCY INFORMATION 1/26/2017 14:54:11 al/pi Page 6 of 22 <br />