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DocuSign Envelope ID: C5C1 1 FD4-56CD-48FD-BBD1 -95F2AFF7112B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Historic Hillsbou h Commission <br />Applicant Organization's Physical Address: 319 N. Churton Sf. Hillsborou h NC 27278 <br />Applicant Organization's Mailing Address: PQ Box 922 Hillsborough, NC 27275 <br />Applicant Organization's Web Address: Burwellschool.ora <br />Executive Director: Kate Faherty <br />Telephone Number. 919.732.7451 E -Mail: Director burwelfschool.or <br />Tax ID Number: 56 - 085036 <br />b) Funding Request <br />List all FY18 -19 Human Services H5 Funding Being Requested <br />For All Programs) and the Proposed Use of Funds (2 -3 lines or less) <br />Ch- apel <br />Hill - HS <br />$15,000 <br />Orange <br />Count -HS <br />$5,000 <br />Total <br />$30,000 <br />8,200 <br />1, 000 <br />9,200 <br />c) To the pest 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 />Executive Dlre or <br />Date <br />Signature:, � �� <br />Board Chairiperson D e <br />AGENCY INFORMATION 1/23/2018 12:09:02 PM Page 8 of 27 <br />