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DocuSign Envelope ID: EA54395E-EA79-461 B-8A4A-AODF56E9A02D <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: A Helping Hand <br /> Applicant Organization's Physical Address: 1502 West NC Highway 54, suite 405 <br /> Durham, NC 27707 <br /> Applicant Organization's Mailing Address: 1502 West NC Highway 54, suite 405 <br /> Durham, NC 27707 <br /> Applicant.Organization's Web Address: www.ahelpinghandnc.orq <br /> Executive Director: Jennifer Ashley <br /> Telephone Number: 919-403-5555 jennifer.ashlev( ahelpinghandnc.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 - HS County-HS <br /> Our Caregiving Collaboration is one part Geriatric $6,000 $6,000 $8,000 $20,000 <br /> workforce enhancement program which serves to <br /> provide vital services to low income seniors. <br /> Totals $20,000 <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 /> Signature: 3( ( 7 <br /> E ecu i -ctor Date <br /> Signature: <br /> � �- HI)', <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/31/2017 3:19:07 PM <br />