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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Piedmont Health Services, Inc. <br />Applicant Organization's Physical Address: 127 Kingston Drive, Chapel Hill, NC 27514 <br />Applicant Organization's Mailing Address: 127 Kingston Drive, Chapel Hill, NC 27514 <br />Applicant Organization's Web Address: www.piedmontheaIth.org <br />Executive Director: Brian Toomey, MSW <br />Telephone Number: (919) 537 -7485 E -Mail: toomeyb(a7piedmonthealth.org <br />Tax ID Number: 56- 0952737 <br />b) Funding Request <br />List a I I FYI 8-19 Human Services (HS) Funding Being Requested <br />For All Pro - grams) 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 />Carrboro Community Health Center <br />$15,000 <br />$15,000 <br />$16,500 <br />$46,500 <br />Totals <br />$15,000 <br />$15,000 <br />$16,500 <br />$46,500 <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 />Brian Toomey Oecutive Director <br />Signature: <br />1 /11,0 bb�R- <br />Date <br />Signature: a, 4,4d_ I /rG12 -,,I - <br />Kenneth Reeb, Jr. Board Chairperson Date <br />AGENCY INFORMATION 1/1612018 2:16:48 PM Page 8 of 25 <br />