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DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Agency Club Nova Community, Inc. <br />Program(s) Club Nova <br />FOR OFFICE USE ONLY <br />Received By <br />Date /Time / <br />Section <br />Subsection <br />1. Cover Page <br />a. <br />® Applicant Contact Information <br />b. <br />® Funding Requests <br />C. <br />® Signed Application Cover Page <br />d. <br />®Signed Disclosure of Conflicts of Interest and Clause <br />2. Agency Information <br />a. <br />® Agency's Years in operation <br />b. <br />® Agency's Purpose /Mission <br />c. <br />® Agency's Types of Services Provided <br />d. <br />® Agency's Experience with Programs <br />e. <br />® Other Pertinent Agency Information <br />f. <br />® Schedule of Positions <br />g. <br />® Living Wage <br />h. <br />® Agency Budget <br />3. Program Information <br />a. <br />® Human Services Needs Priority <br />b. <br />® Type of Program <br />A separate Section 3 is <br />c. <br />® Agency Collaboration <br />required for each program. <br />d. <br />® Summary of Program <br />e. <br />® Description of Identified Need <br />f. <br />® Description of Population to be Served <br />g. <br />® Program Staffing, Capacity, & Expertise <br />h. <br />® Program Implementation Timeline <br />L <br />® Value of Investment <br />j. <br />® Impact of Reduced /No Allocation <br />k. <br />® Other Pertinent Information <br />I. <br />® Target Population /Beneficiary Chart <br />M. <br />® Work Statement <br />n. <br />® Program Budget, Detail, & Cost per Individual <br />4. Attachments <br />a. <br />® Audit: Organizations receiving $300,000 or more in Federal <br />financial assistance, and /or organizations with more than $500,000 <br />of receipts and expenditures in a fiscal year, must secure an audit. <br />b. <br />® IRS Federal Form 990 <br />c. <br />® NC Solicitation License <br />d. <br />® IRS Federal Tax - Exemption Letter <br />e. <br />® Certificate of Insurance <br />f. <br />® List of Board of Directors <br />g. <br />® Solid Waste Program Fee (SWPF) Verification <br />Application Submittal Checklist 2/9/2017 1:51:06 PM Page 1 of 26 <br />