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DocuSign Envelope ID: COBB49A6 -D1 E9- 42DE- 8E8D- 7583E683E1E2 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Orange County Living Wage <br />Applicant Organization's Physical Address: 218 Lake Manor Road, Chapel Hill NC 27516 <br />Applicant Organization's Mailing Address: PO Box 1502, Carrboro NC 27510 <br />Applicant Organization's Web Address: www.orangecountylivingwage.org <br />Executive Director: Susan Romaine <br />Telephone Number: 919 - 619 -3406 E -Mail: susan @orangecountylivingwage.org <br />Tax ID Number: 47- 4595087 <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 />Orange <br />Total <br />-HS <br />Hill - HS <br />s County-HS <br />Living wage certification program <br />Digital infrastructure support: website hosting fees, <br />$1,500 <br />_ <br />CRM app NationBuilder and email service <br />f <br />Hourly compensation: certification coordinator (60 <br />$2,500 <br />$2,500 <br />$20,000 <br />hrs 1 month); bookkeeping (12 hrs 1 month): <br />technical support for website updates and <br />maintenance along with newsletter and employer "e- <br />blasts" (16 hrs / month) <br />Certification materials: framed certificates and decals <br />$1000 <br />to publicly identify living- wage - certified employers <br />-Marketing and promotional materials: brochures, <br />$6,500 <br />living -wage supporter cards, etc., to expand program <br />reach and engage consumers with living wage <br />employers <br />Accounting: CPA support for financial and tax - related <br />$1000 <br />services <br />Totals <br />$6,000 <br />$9,000 <br />$20,000 <br />$35,000 <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 duty authorized by the governing board of the <br />applicant. <br />Signature <br />Signature: <br />(,t <br />E ecutive Director <br />�1 <br />(- dv - tr <br />Date <br />r -ab-rg <br />Board Chairperson Date <br />AGENCY INFORMATION 1/20/2018 11:16:44 AM Page 1 of 18 <br />