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DocuSign Envelope ID: 717C8AE2- 4D6E- 4E46- A9A7- F4213973D039 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Club Nova Community, Inc. <br />Applicant Organization's Physical Address: 103 -D W Main St, Carrboro, NC 27610 <br />Applicant Organization's Mailing Address: 103 -D W Main St Carrboro NC 27610 <br />Applicant Organization's Web Address: www.clubnova.orq <br />Executive Director: Karen Kincaid Dunn <br />Telephone Number: 919- 968 -6682 <br />Tax ID Number: 27- 0103430 <br />E -Mail: adminRclubnova.org <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 />Ch_ apel <br />Hill - HS <br />Orange <br />Count -HS <br />Total <br />-HS <br />Ex. Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 <br />$15,000 <br />$5,000 <br />$30,000 <br />Critical Safety Net— Health and Wellness <br />$20,000 <br />$20,000 <br />Critical Safety Net - Operating <br />$20,000 <br />$20,000 <br />Employment/Education; Transportation: expenses and <br />salary; Critical Safety Net <br />$120,000 <br />$120,000 <br />Totals <br />$170,000 <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 />Executive Director Date <br />Signature: Al, RJKI.14 <br />AE3Vard Chairperson Date <br />Agency Information 1/23/2018 1:00:30 PM Page 8 of 3,1 <br />