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Orange County Health Department 3 <br />1 <br />FY 2007 Community Health Center Grants <br />ORGANIZATIONAL INFORMATION & SIGNATURE SHEET <br />Organization Name: Orange County Health Department <br />Organization EIN: # <br />Mailing Address: 300 West Tryon Street, PO Sox 8181, Hillsborough, NC 27278 <br />Organization Tvne (check one) <br />^ FQHC ^ Free Clinic ^ Free Pharmacy <br />X Health Department ^ Hospital ^ Rural Health Clinic <br />^ AHEC Program ^ Other (specify) <br />Organization Fiscal Year: FY 06-07 <br />Contact Person: Wayne Sherman, Personal Health Services Director <br />Email Address: wsherman@co.orange.nc.us <br />Phone Number: (919) 245-2402 <br />Grant Request: Category I -Program Grant $44,769 <br />Category II -Capital Grant $25,601 <br />Total Request (cannot exceed $75,000) $70,370 <br />Grant Application Submitted Bv: <br />Signature: <br />Name: Rosemary Summers <br />Organization Name: Orange County Health Department <br />Date: <br />Title: Health Director <br />3 <br />