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DocuSign Envelope ID: 74839431 - 9216- 429F- BFA4- 2AC6473BD9D3 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Pathways to Chan a Inc. <br />Applicant Organization's Physical Address: 950 Car orate Drive Suite 408 <br />Hillsborough, NC 27278 <br />Applicant Organization's Mailing Address: 960 Corporate Drive, Suite 408, <br />Hillsborough, NC 27278 <br />Applicant Organization's Web Address: pathwaystochangenc.orq <br />Executive Director: Kathryn Bauman <br />Telephone Number: (919) 245 -3309 <br />Tax 1D Number: 58- 2063924 <br />E -Mail: kbaumangpathwaystochangenc.oLg <br />bj 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 />Ex. Youth Afterschool Program <br />l $10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />26 -week NG- Certified Partner Abuse Intervention <br />$3,500 <br />$6,000 <br />$4,500 <br />$14,000 <br />(also called Batterer Intervention or Abuser <br />Treatment <br />10 -week Anger Management Program <br />$2,500 <br />$3,000 <br />$2,504 <br />$8,400 <br />Totals <br />$6,000 <br />$9,000 <br />$7,000 <br />$22,000 <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 />Executi a blrector <br />Signature.'�.�. <br />Board Chairperson <br />1 23 zol <br />Date <br />_/p-3-10r8 <br />Dat <br />AGENCY INFORMATION 1/2312018 10:58:29 AM Page 8 of 32 <br />