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DocuSign Envelope ID:A6B9A80E-25C6-439A-A77D-6C8B04CDDFE2 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency _Peidmont Wildlife Center Received By <br /> Program(s) (1)Earthkeepers Afterschool Date/Time / <br /> (2)Youth & Teen Nature Day Camp <br /> 1. Cover Page a. ❑Applicant Contact Information <br /> b. ❑Funding Requests <br /> c. ❑Signed Application Cover Page <br /> d. ❑signed Disclosure of Conflicts of Interest and Clause <br /> e. <br /> 2. Agency Information a. ❑Agency's Years in operation <br /> b. ❑Agency's Purpose/Mission <br /> c. ❑Agency's Types of Services Provided <br /> d. ❑Agency's Experience with Programs <br /> e. ❑Other Pertinent Agency Information <br /> f. ❑Schedule of Positions <br /> g. ❑Living Wage <br /> h. ❑Agency Budget <br /> 1/12/2017 2:56:42 PM I:' 2 lr 29 <br />