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DocuSign Envelope ID:3B67A5FD-6776-4322-9152-0531CA4BC4BD XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> FOR OFFICE USE ONLY <br /> Agency _Public Gallery of Carrboro <br /> Received By <br /> Program(s) _WCOM Community Radio Date/Time / <br /> Section Subsection <br /> 1. Cover Page a. ® Applicant Contact Information <br /> b. ® Funding Requests <br /> C. ® Signed Application Cover Page <br /> d. ®Signed Disclosure of Conflicts of Interest and Clause <br /> 2. Agency Information a. ® Agency's Years in operation <br /> b. ® Agency's Purpose/Mission <br /> c. ® Agency's Types of Services Provided <br /> d. ® Agency's Experience with Programs <br /> e. ® Other Pertinent Agency Information <br /> f. ® Schedule of Positions <br /> g. ® Living Wage <br /> h. ® Agency Budget <br /> 3. Program Information a. ® Human Services Needs Priority <br /> b. ® Type of Program <br /> A separate Section 3 is c. ® Agency Collaboration <br /> required for each program. d. ® Summary of Program <br /> e. ® Description of Identified Need <br /> f. ® Description of Population to be Served <br /> g. ® Program Staffing, Capacity, & Expertise <br /> h. ® Program Implementation Timeline <br /> L ® Value of Investment <br /> j. ® Impact of Reduced/No Allocation <br /> k. ® Other Pertinent Information <br /> I. ® Target Population/Beneficiary Chart <br /> M. ® Work Statement <br /> n. ® Program Budget, Detail, & Cost per Individual <br /> 4. Attachments a. ® Audit: Organizations receiving $300,000 or more in Federal <br /> financial assistance, and/or organizations with more than $500,000 <br /> of receipts and expenditures in a fiscal year, must secure an audit. <br /> b. ® IRS Federal Form 990 <br /> c. ® NC Solicitation License <br /> d. ® IRS Federal Tax-Exemption Letter <br /> e. ® Certificate of Insurance <br /> f. ® List of Board of Directors <br /> g. ® Solid Waste Program Fee (SWPF) Verification <br /> Application Submittal Checklist 2/8/2017 9:06:10 AM P a g e 1 o f 1 8 <br />