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DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: the Historical Foundation of Hillsborough & <br /> Orange County <br /> Applicant Organization's Physical Address: 201 North Churton St., Hillsborough, NC <br /> 27278 <br /> Applicant Organization's Mailing Address: 201 North Churton St., Hillsborough, NC <br /> 27278 <br /> Applicant Organization's Web Address: www.orangenchistory.org <br /> Executive Director: Candace Midgett <br /> Telephone Number:_(919) 732-2201 E-Mail: director @orangenchistory.org <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 - County- <br /> HS HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and <br /> materials for youth activities and projects <br /> Orange County Historical Museum: heritage <br /> education; education through exhibits; <br /> preservation and conservation (includes $7260.00 $7260.00 <br /> research) <br /> Totals $7260.00 $7260.00 <br /> AGENCY INFORMATION 2/9/2017 1:10:02 PM P :1e 7 o 3 8 <br />