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DocuSign Envelope ID:42FC26E4-086D-47F4-A291-0A9A8706CA60 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: El Centro Hispano <br /> Applicant Organization's Physical Address:201 West Weaver Street, Carrboro NC 27510 <br /> Applicant Organization's Mailing Address: 2000 Chapel Hill Road, Suite 26A <br /> Durham NC 27707 <br /> Applicant Organization's Web Address: www.elcentronc.orq <br /> Executive Director: Pilar Rocha-Goldberg <br /> Telephone Number: (919) 687-4635 Ext. 43 E-Mail: prochaelcentronc.orq <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 -HS County-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Community Support Services (salaries, rent& utilities, 5,000 15,000 20,000 40,000 <br /> communications, supplies, equipment, forums) <br /> Center for Employment and Leadership (salaries, rent 5,000 10,000 15,000 25,000 <br /> & utilities, supplies, program expenses) • <br /> Education Services: PreK-Adult(staff salaries, 10,000 5,000 15,000 <br /> supplies, program expenses, <br /> Totals J 20,000 30,000 35,000 85,000 <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 /> (Jr, <br /> . t'i Q <br /> Signature: (A o(( <br /> Executive Director Date <br /> Signature: 04‘■,,. ! 1/ 7 <br /> S=oard Chair.-rson Date <br /> AGENCY INFORMATION 1/30/2017 4:37:40 PM Page 3 of 3& <br />