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DocuSign Envelope ID:C4C09F35-022B-45DE-8313-4A1ED7AF458B XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The ArtsCenter <br /> Applicant Organization's Physical Address: 300-G East Main St, Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: SAME <br /> Applicant Organization's Web Address: www.artscenterlive,org <br /> Executive Director: Daniel Y. Mayer <br /> Telephone Number: 919-929-2787 x 217 E-Mail: dmaYer(a)-artscenterlive.org <br /> Tax ID Number: 51-0198497 <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> -HS Hill-HS County-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> General Support Arts Programs $20,000 $17,500 $37,500 <br /> ArtsCenter Youth Education Department $15,000 $15,000 <br /> Totals $20,000 $17,500 $15,000 $52,500 <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 /> Signatu 7 <br /> Execu# ' D- c Date <br /> , <br /> Signature: <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/27/2017 12:56:30 PM Page 6 of 20 <br />