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DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Table Ministries, Inc. <br />Applicant Organization's Physical Address: 209 E. Main Street, Carrboro, NC 27510 <br />Applicant Organization's Mailing Address: same as above <br />Applicant Organization's Web Address: www.tablenc.org <br />Executive Director: Ashton Tippins <br />Telephone Number: (919)636 -4860 E -Mail: info(a)tablenc.org <br />Tax ID Number: 26- 1471735 <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 />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 />Food <br />9000 <br />9000 <br />9000 <br />27000 <br />Program Staff Support <br />3000 <br />3000 <br />3000 <br />9000 <br />Rent <br />3000 <br />3000 <br />3000 <br />9000 <br />Totals <br />15,000 <br />15,000 <br />15,000 <br />$45,000 <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: ' �1t✓ ,� � 1 <br />Executive Director <br />I t�� <br />Signature: <br />B and Cha' person <br />1/19/18 <br />Date <br />1/23/18 <br />Date <br />AGENCY INFORMATION 1/23/2018 3:44:19 PM Page 7 of 21 <br />