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DocuSign Envelope ID:4FF28E49-EE56-4A40-9331-F55AA8A05998 <br /> EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Institute of Art Therapy, Inc. <br /> Applicant Organization's Physical Address: 200 N. Greensboro St., D-6, Carrboro, NC, 27510 <br /> Applicant Organization's Mailing Address: 200 N. Greensboro St., D-6, Carrboro, NC, 27510 <br /> Applicant Organization's Web Address: www.ncati.org <br /> Executive Director: Hillary Rubesin <br /> Telephone Number: 610-348-7253 E-Mail: hrubesin(o)_ncati.org <br /> Tax ID Number: 26-3447555 <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 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 /> Newcomer's Art Therapy Program $10,000 $15,000 $5000 $30,000 <br /> Clinician pay for newcomer child and adult art therapy <br /> services, art materials, art show costs, rent, research, <br /> and interpretation. <br /> Totals $10,000 1 $15,000 1 $5,000 $30,000 <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: � Z 1/21/2018 <br /> Executive Nrector Date <br /> Signature. �� 1/21/2018 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 1/23/2018 10:01 :04 AM Page 7 of 24 <br />