Orange County NC Website
FOR THE APPLICANT: <br />Date <br />Applicant's Federal Tax I.D. Number (required) <br />Date <br />BY: <br />Signature <br />ICon~,oth T (:hauiniic <br />Typed Name <br />Finance Director <br />Title <br />FOR THE STATE: <br />BY: <br />Signature <br />Typed Name <br />Title <br />Reviewed 2/8/02 Page 4 of 7 Rev. 06/01 <br />