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DocuSign Envelope ID:3B67A5FD-6776-4322-9152-0531CA4BC4BD XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Public Gallery of Carrboro <br /> Applicant Organization's Physical Address: 300-G East Main St: Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 300-G East Main St,; Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.wcomfm.org <br /> Executive Director: NONE <br /> Telephone Number Board Chair: 919-675-2787 Board chair E-Mail: art(@artmenius.com <br /> Tax ID Number: 56-2010901 <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 Count -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 /> WCOM Community Radio operational expenses $1,000 $0 $1,000 $2,000 <br /> Totals $1,000 $0 $1,000 $2,000 <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: Not Applicable N/A <br /> Executive Director Date <br /> Signature: P <br /> January 24, 2017 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 2/8/2017 9:06:10 AM Page 2 of 18 <br />