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DocuSign Envelope ID: 4B292955- 9A36- 47C6- BDDE- 4E9CDOBA074D <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Volunteers for Youth, Inc. <br />Applicant Organization's Physical Address: 205 Lloyd Street Suite 103 Carrboro NC 27510 <br />Applicant Organization's Mailing Address: 205 Lloyd Street, Suite 103 Carrboro, NC 27510 <br />Applicant Organization's Web Address: www.yolunteersforyouth.org <br />Executive Director: Susan Worley <br />Telephone Number: 919 - 967 -4511 E -Mail: susan(cD-volunteersforyouth.org <br />Tax ID Number: 58- 1457945 <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 Carrboro Chapel Oranne Total <br />MS I Will - MR I Cnnn#v -MIR <br />Mentoring community service; .& teen.court ..programs $41000 $13,500 $121.000. $291500 <br />Portion of program coordinators' salaries, youth <br />activities, and general operating expenses <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 />Signature: <br />Executive Director <br />Signature: L o� <br />Boar Chai erson <br />1-16,19 <br />Date <br />l- r(0 -Zoi� <br />Date <br />AGENCY INFORMATION 1/16/2018 11:47:11 AM Page 8 of 26 <br />