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DocuSign Envelope ID: D13694BA-66F1-4441-9114-5334F2B6AC3D XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Planned Parenthood South Atlantic <br /> Applicant Organization's Physical Address: 1765 Dobbins Drive, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: 1765 Dobbins Drive, Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: www.ppsat.orq <br /> Executive Director: Jenny Black <br /> Telephone Number: 919-833-7526, ext. 6140 E-Mail: jenny.blackppsat.orq <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 /> Proqram I Carrboro 1 Chapel Orange Total <br /> -HS Hill -HS Coun -HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for outh activities anstprojects <br /> Sexual Health Education and Outreach $1,000 $2,500 $20 000 I 23,500 <br /> I <br /> Totals 1 I <br /> 1 1 <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 /> II <br /> 7 ,, <br /> ( ( I II ,,,, <br /> 1 h o I i- <br /> Signature: _0 2 70./ <br /> ...._.... ....._,... ...........______ <br /> 6(ecutive l irector Date <br /> Signature: -,.._-F -.., - 17 <br /> Bo / <br /> ),.. , 5,0 ,Chairperson Date <br /> AGENCY INFORMATION 1/26/2017 1:47:36 PM p , g II, 6 o f 27 <br />