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KCHEARgITP BLE~'I'R~[ SUTs <br />Healthy Carolinians Partnership Support Initiative <br />Applicant Cover Sheet <br />Name of <br />Orange County Health Department <br />Name of Healthy Carolinians <br />if different than above <br />Healthy Carolinians of Orange County <br />Mailing Address <br />2501 Homestead Rd. <br />City <br />Chapel Hill <br />Healthy Carolinians Partnership Contact Person: <br />Name <br />Bobbie Jo Munson <br />Mailing Address <br />2501 Homestead Rd. <br />Telephone <br />919-968-2022 Ext. 291 <br />FAX <br />919-969-4777 <br />City <br />Chapel Hill <br />Zip code <br />27516 <br />E-mail <br />bmunsonQco. orange. nc. us <br />r: Partnership is Certified through o5/oli2oo8 <br />mmldd/yy <br />r` Partnership expects to be Certified by <br />mm/ddlyy <br />Applicant is: <br />r' Separately incorporated Healthy Carolinians Partnership (attach IRS 501 c3 letter) <br />Other non-profit (attach IRS 501 c3 letter) <br />Governmental agency <br />>~ We have attached a roster of our current Healthy Carolinian Partnership members. <br />~- We have attached a copy of the applicant's most recent audit (not required of <br />governmental agencies). <br />~ We are requesting the following grant dollars -maximum $30,000 over three <br />years with limit of $10,000 in any one year. <br />Year One $10,000 <br />Year Two $10,000 <br />Year Three $10,000 <br />County <br />Orange <br />Zip code <br />27516 <br />Telephone <br />919-968-2022 Ext. 291 <br />Title <br />Healthy Carolininas Coordinator <br />a <br />Page 1 of 4 <br />