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DocuSign Envelope ID: DB2FC63F- 0403 - 4403- BF86- OF5CB206F3F3 <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 Rural Alliance <br />Applicant Organization's Physical Address: 4901 Schley Road, Hillsborough, NC 27278 <br />Applicant Organization's Mailing Address: PO Box 642, Hillsborough, NC 27278 <br />Applicant Organization's Web Address: www.ocrahub.com <br />Executive Director: Norma White <br />Telephone Number: 919- 732 -8527 <br />Tax iD Number: 81- 4489249 <br />E -Mail: n.b.white0Dembargmail.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 />Program <br />Carrboro <br />Chapel <br />Hill - HS <br />Oran a <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 />Ideal goal is to deliver meals to 120 seniors two times <br />a week by the end of 2018 <br />$40,000 <br />$40,000 <br />Totals <br />$40,000 <br />$40,000 <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: Wk,-.t Z- &e." <br />Norma B. White, Executive Director <br />Signature: <br />Os�w,,�e <br />/1" //,p <br />Date <br />Ili 1 /l8 <br />Archie Daniel, Vice President Date <br />AGENCY (NFORMAT(ON 1/11/2018 1 :52:04 PM <br />Page 8 of 25 <br />