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DocuSign Envelope ID: 3F05AA6E -4F62- 4678- 8F07- 34D6E1679E9A <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Farmer Foodshare <br />Applicant Organization's Physica Address: 902 N. Mangum Street, Durham, NC 27701 <br />AW <br />Applicant Organization's Ma' ' A ss: P.O. Box 2873, Chapel Hill, NC 27515 <br />Applicant Organization's Web A ss: www.farmerfoodshare.org <br />Executive Director: Gini Bell # <br />Telephone Number: 919.360.6358 E -Ma' ni farmerfoodshare.or <br />Tax ID Number: 27- 3717889 <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 />Orange <br />Total <br />- HS <br />Hill - HS <br />County-HS <br />Donation Station Program — Farmers market- <br />$5,000 <br />$5,000 <br />$10,000 <br />$20,000 <br />based program that supports local Orange <br />County farmers and organizations working to <br />increase access to fresh food to community <br />members in need. <br />Totals <br />$5,000 <br />$5,000 <br />$10,000 <br />$20,000 <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 />Executive Director <br />Board Chairperson <br />1/23/2018 <br />Date <br />1/23/2018 <br />Date <br />AGENCY INFORMATION 2/16/2018 1:09:05 PM Page 8 of 20 <br />