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DocuSign Envelope ID: E8DFACF7 -45BE- 435E- 9B5A- BB177E968F07 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Duke University Health System, Inc. d /bla Duke HomeCare & Hospice <br />Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br />Applicant Organization's Mailing Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br />Applicant Organization's Web Address: https: / /dhch.duhs.duke.edu <br />Executive Director: Kevin R. Carter, Director <br />Telephone Number: 919.620.3853 E -Mail: kevin.carter@duke.edu <br />Tax ID Number: 56- 2070036 <br />b) Funding Request <br />List all FY18 -19 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 <br />Chapel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />HS <br />Dube HomeCare & Hospice <br />$3,900 <br />$3,200 <br />$1,100 <br />$8,300 <br />Totals <br />$3,900 <br />$3,200 <br />$1,200 <br />$8,300 <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: �. <br />Director <br />Signature: <br />Board Chairperson <br />I I -I <br />Date <br />Date <br />AGENCY INFORMATION 1/19/2018 12:42:41 PM Page 1 of 11 <br />