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DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 <br />EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Club Nova Community, Inc. <br />Applicant Organization's Physical Address: 103 -D W Main St, Carrboro, NC 27510 <br />Applicant Organization's Mailing Address: 103 -D W Main St, Carrboro, NC 27510 <br />Applicant Organization's Web Address: www.clubnova.org <br />Executive Director: Karen Kincaid Dunn <br />Telephone Number: 919- 968 -6682 E -Mail: kdunn @clubnova.org <br />Tax ID Number: 27- 0103430 <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 />Program <br />Carrboro Cha elel Orange Total <br />='HS Hill - HS County -HS <br />Ex 'YouthAfterschool Program $10 000 $15:080 $5,000 $30,000 <br />Afterschool Program Coordinator salary and materials <br />for':. outh activities and projects . ` <br />Critical Safety Net, Health and Wellness $20,000 $20,000 <br />Critical Safety Net - Operating $20,000 $20,000 <br />Employment/Education, Transportation: expenses and $120,000 $120,000 <br />salary- Increase to Living Wage to become Orange <br />County Living Wage Certified, Critical Safety Net <br />Totals $20.,000 ;':. $20,000 $120,000 $160,000 <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 />Signature. n_�� r viv � � - j -Le S61 A ' 112 v� F <br />Ex cutive Director Dat <br />Signature: K041-41 I - <br />Board Chairperson Date <br />AGENCY INFORMATION 1/31/2017 1:58:44 PM Page 2 of 23 <br />