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DocuSign Envelope ID: A2273A84- 8827 - 4141- A87E- C8CFF83C3936 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Chapel Hill - Carrboro Human Rights Center dba Refugee <br />Communijy PPartnership <br />Applicant Organization's Physical Address: 117 W Main St, Carrboro, NC 27510 <br />Applicant Organization's Mailing Address: PO Box 461. Carrboro, 27510 <br />Applicant Organization's Web Address: refugeecommunitypartnership.o[g <br />Executive Director: Madison Haves <br />Telephone Number: 919 - 590 -5910 E -Mail: Madison (Drefugeecommunitypartnership .org <br />Tax ID Number: 26- 3608741 <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 />Oranae <br />Coun -HS <br />Total <br />- HS <br />Bridge Builders Program staff salary support; <br />insurance coverage; interpreter services; community <br />feedback sessions 31 ear <br />8,300 <br />7,200 <br />14,500 <br />$30,000 <br />ESL Program staff salary support; volunteer <br />management; bi- annual program evaluation; student <br />progress monitoring; reporting <br />700 <br />1,000 <br />1,000 <br />$2,700 <br />Totals <br />$9,000 <br />$8,200 <br />$15,500 <br />$32,700 <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: VX�JL 12 v <br />Executive D' ector Date <br />Signature: thdW <br />Board Chairperson Date <br />AGENCY INFORMATION 1/22/2018 2:02:18 PM Page 7 of 36 <br />