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DocuSign Envelope ID:E519448F-9F6D-4100-BF62-D7625621FFEB XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Orange County Partnership for Young Children <br /> Applicant Organization's Physical Address: 120 Providence Road, Suite 101, Chapel Hill, NC <br /> 27514 <br /> Applicant Organization's Mailing Address: 120 Providence Romd, Suite 101. Chapel HiU, NC <br /> 27514 <br /> Applicant Organization's Web Address: yvvvvv.Vnangounnartotart orq <br /> Executive Director: Robin Pulver <br /> Telephone Number: 919-967-9091 E-Mail: rpulverorangesmartstart.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-10 Human Services (HS) Funding Being Requested— <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program, Carrbunm Chapel Orange Total, <br /> - HS Hill 'HS Cmunty~HS <br /> Ex Youth Afemuhoo| Program $10.000 $16.000 $5,000 � ` $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Transplanting Traditions Community Farm $7,500 $7,600 $7,500 $22,500 <br /> Staffing, contractual services, and materials to support <br /> the activities of Transplanting Traditions Community <br /> Farm, a community farm for refugees from Burma. <br /> Contracted services include a native translator from <br /> Burma. <br /> _ <br /> Totals <br /> AGENCY INFORMATION 1/31/2017 3:59:06 PM Page 3 of 18 <br />