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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Piedmont Wildlife Center <br /> Applicant Organization's Physical Address: 364 Leigh Farm Rd; Durham, NC 27707 <br /> Applicant Organization's Mailing Address: same as physical address <br /> Applicant Organization's Web Address: www.piedmontwildlifecenter.org <br /> Executive Director: Gail Abrams <br /> Telephone Number: 919-489-0900 E-Mail: director @piedmontwildlifecenter.org <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Procirams) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill -HS County- <br /> 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 /> Youth Afterschool Program at Carrboro $2,500 $2,500 <br /> Elementary School - PWC program salaries, <br /> materials, travel; teacher training; and <br /> incentives <br /> Summer Camp Program - staff salaries, $2,000 $10,000 $12,000 <br /> materials,travel, and incentives allowing us to <br /> offer up to 46 partial and full scholarships <br /> Totals $2,500 $2,000 $5,500 $14,500 <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. <br /> Signature: Gail Abrams 1/30/2017 <br /> Executive Director Date <br /> Signature: Martha Wewer 1/30/2017 <br /> Board Chairperson Date <br /> 1/12/2017 2:56:42 PM II I:' 4 ,r 29 <br />