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DocuSign Envelope ID: 557EOBA8 -OFDF- 4943- B10E- 6AB96D651F4B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: EmPOWERment Inc. <br />Applicant Organization's Physical Address: 109 N. Graham Street, Suite 200, Chapel Hill, NC 27516 <br />Applicant Organization's Mailing Address: 109_N. Graham Street, Suite 200, Chapel Hill, NC 27516 <br />Applicant Organization's Web Address: www.empowermentinc- nc.org <br />Executive Director: Delores Bailey <br />Telephone Number: 919- 967 -8779 <br />Tax ID Number: 56- 1969772 <br />E -Mail: empowermentinencOgamail.com <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 />Pro-gram <br />Card oro <br />Chapel <br />Hill - HS <br />Orange <br />County--HS <br />Total <br />- HS <br />Ex.:Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Property manager salary and materials for Rental <br />Property Pro ram <br />$20,000 <br />$20,000 <br />$30,000 <br />$70,000 <br />Totals 1 <br />$20,000 <br />L$20,000 <br />1 $30,000 <br />1 $70,000 <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 duly authorized by the governing board of the <br />applicant, <br />Signature: <br />Signature: <br />WIN- <br />"Executive Director <br />rafd'cKairperson <br />l 12 _,Z i <br />Date <br />Date <br />AGENCY INFORMATION 1/22/2018 1:34:08 PM Page 7 of 23 <br />