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DocuSign Envelope ID: 8E8982E7 -EFF8- 4214- 979D- 9D572ED220CC <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Hillsborough Arts Council <br />Applicant Organization's Physical Address: 102 North Churton Street <br />Applicant Organization's Mailing Address <br />Applicant Organization's Web Address <br />Executive Director: <br />Telephone Number: <br />Electronic Mail: <br />Tax ID Number: <br />Hillsborouah. NC 27278 <br />102 North Churton Street <br />Hillsborough, NC 27278 <br />HillsboroughArtsCouncil.org <br />N/A -Neil Stutzer, Chair <br />919 643 -2500 <br />info (c-DHillsboroughArtsCouncil.org <br />56- 2163979 <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 />Organizational Development for Community <br />Outreach and Sustainability <br />$16,500 <br />$16,500 <br />Totals <br />$16,500 <br />$16,500 <br />The proposed funding is for expanding the Program Coordinator position from half -time <br />to full -time. <br />c) To the best of my knowledge and belief all information and data in this <br />application is true and current. The document has been duly authorized by the <br />governing board of the applicant. <br />Signature: N/A <br />Executive Director <br />Signature: /yell yeaeZee <br />Board Chairperson <br />Date <br />1/17/2018 <br />Date <br />AGENCY INFORMATION 2/11/2018 4:28:29 PM Page 6 of 26 <br />