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DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's. Legal Name: Chapel Hill Training Outreach Proiect, Inc. <br />Applicant Organization's Physical Address: 800 Eastowne Drive, Suite 105 <br />Applicant Organization's Mailing Address: 800 Eastowne Drive, Suite 105 <br />Applicant Organization's Wed Address: www.chtop,org <br />Executive Director: Mike Mathers <br />Telephone Number: 919 490 5577 <br />Tax ID Number. 58- 204352 <br />E -Mail: mmathers@chtop.ora <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 />Carrtboro <br />Chaoet <br />Hill - HS <br />Orance <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 />$5,400 <br />$30,000 <br />KidSCope Outreach: Early Childhood Mental Health <br />therapist salary and program expenses <br />$3,400 <br />$6,000 <br />$75,000 <br />$84,000 <br />Totals <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 />�2Signature., L <br />Executive Director <br />Signature: :r V� -� -�.� L_ '�.,Q�L � <br />Board Chairperson <br />1 bb <br />Da e <br />(late <br />I /r i I A V_ <br />AGENCY INFORMATION 1/9/2018 2:45:48 PM Page 7 of 2' <br />d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br />CLAUSE <br />AGENCY INFORMATION 1/22/2018 3:23:54 PM <br />