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State of North Carolina <br />Division of Social Services <br />Contract Application <br />E. Contract Identification: <br />1. Provider <br />Page 2 of 7 <br />a. Name of Contract Administrator Kathy Brvan _ <br />Tel. # :732-8124 <br />b. Name of Pro~am Contact Person: Antonia Pedroza <br />Tel. #: 732-8124 <br />c. Program Name, Location and Mailing Address: <br />500 Valley Forge Rd. <br />d. Additional Service Delivery Sites: <br />e. Status : ()Public (X) Private, non-profit <br />()Private, for Profit ( )Individual <br />f. Provider Contract ID #: CRF.S(1 <br />2. Count Department of Social Services <br />a. Name of Contract Administrator: Nancy Coston <br />Tel. # : 245-2800 <br />b. Name of Services Program Contact Person: <br />Tel. #: 245-2800 <br />Gwen Price <br />c. Address of County Department of Social Services: <br />300 W Tryon Street <br />Hillsborough NC 27278 - <br />8 <br />