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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A FOR OFFICE USE ONLY <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Received By <br /> Date/Time / <br /> Agency Orange County Historical Museum <br /> Program(s) Heritage Education; Education through Exhibits; Preservation and <br /> conservation includes research <br /> Section Subsection <br /> 1. Cover Page a. x Applicant Contact Information <br /> b. x Funding Requests <br /> c. x Signed Application Cover Page <br /> d. xSianed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. x Agency's Years in operation <br /> b. x Agency's Purpose/Mission <br /> c. x Agency's Types of Services Provided <br /> d. x Agency's Experience with Programs <br /> e. ❑ Other Pertinent Agency Information <br /> f. x Schedule of Positions <br /> g. x Living Wage <br /> 3. Program Information a. x Human Services Needs Priority <br /> b. x Type of Program <br /> A separate Section 3 is c. x Agency Collaboration <br /> required for each d. x Summary of Program <br /> program. e. x Description of Identified Need <br /> f. x Description of Population to be Served <br /> g. x Program Staffing, Capacity, & Expertise <br /> h. x Program Implementation Timeline <br /> i. x Value of Investment <br /> j. x Impact of Reduced/No Allocation <br /> k. ❑ Other Pertinent Information <br /> I. x Target Population/Beneficiary Chart <br /> m. x Work Statement <br /> n. x Program Budget, Detail, & Cost per Individual <br /> Application Submittal Checklist 2/9/2017 1:10:02 PM II: M: a u^ 5 o II 5 8 <br />