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DocuSign Envelope ID: 42882613- 58E8 -4BA1- 9376- A348D7FC56CA <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />Applicant Organization's Legal Name: Boys & Girls Clubs of Durham and Orange Counties <br />Applicant Organization's Physical Address: 808 E Pettigrew St; Durham, NC 27701 <br />Applicant Organization's Mailing Address: P.O. Box 446 Durham, NC 27702 <br />Applicant Organization's Web Address: ynw.bggdop.grg <br />Executive Director: Jerome Levis) <br />Telephone Number: (919)- 687 -4517 E -Mail: _i[evisvCcDbacdoc.czrcJ <br />Tax ID Number: 56- 6001906 <br />b) Funding Request <br />List all FY18 -19 Human Services (H$) Funding Being Requested — <br />For All Programs) and the Proposed Use of Funds (2 -3 lines or less) <br />Prrogmm <br />Carrboro <br />Chapel <br />-H <br />Orange <br />-County- <br />Total <br />- HS <br />Youth After School IMPACT Program <br />After School Program Coordinator salary and <br />materials for youth activities and projects <br />$15,000 <br />$10,000 <br />$5,000 <br />$30,000 <br />Totals <br />$15,000 <br />$10,000 <br />$5,000 <br />$30,000 <br />c) To the best of my knowledge and belief all information and data in this application is true <br />and current. The document has been duly authorized by the governing board of the <br />applicant. <br />Signature: 1 19 �g <br />xecutive Director Date <br />j <br />s <br />Signature: k - 4::7� /jqjw <br />B a`d Chaimerson Date <br />