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Agency _Peidmont Wildlife Center <br />Program(s) (1)Earthkeepers Afterschool <br />(2)Youth & Teen Nature Day Camp, <br />.............................................................. ............................... <br />FOR OFFICE USE ONLY <br />Received By <br />Date /Time / <br />1. Cover Page <br />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 <br />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 2 Of 29 <br />