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DocuSign Envelope ID 71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Orange Congregations In Mission, Inc. <br /> Applicant Organization's Physical Address: 300 Millstone Drive, Hillsborough, NC 27278 <br /> Applicant Organization's Mailing Address:300 Millstone Drive, Hillsborough, NC 27278 <br /> Applicant Organization's Web Address:www.ocimnc.orq <br /> Executive Director: (Rev.) Sharon S. Freeland <br /> Telephone Number: 919-732-6194 E-IVIail:ocimsrm( Rmbargmail.com <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested— <br /> For AO Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> -HS Hill-HS Count -HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> foryouth activities and projects <br /> Meals on Wheels 17,000 17,000 <br /> Food purchases <br /> Meals on Wheels 17,000 17,000 <br /> Expansion and utilization of Cedar Grove Community <br /> Center part time employee salary and mileage <br /> Samaritan Relief Ministry 58,415 58,415 <br /> Food, rent/utility assistance,program manager salay_ <br /> — <br /> Totals 92,415 92,415 <br /> C)To the best of my knowledge and belief all information and data in this application is true <br /> and current. The document has been duly authorized by the governing board of the <br /> applicant n <br /> 1411)'';1,,eit '4 ..L-,(// <br /> Signature: l , -,,_ ■. , &e,e__-, j 1 2,,,)I 11 <br /> Executive Director Date ' <br /> Signature: —"v (;) )11,--edvievl--) <br /> 1 <br /> e oa - <br /> rd Chair-person Date <br /> i 1 2,01 --1 <br /> AGENCY INFORMATION 1/30/2017 4:48:17 PM I. i) ,7 3 fJ (, ' 2 3 <br /> , 1 <br /> j1, <br /> i <br /> i <br /> i4 <br /> 0 //;i' <br /> 1%, 1 <br />