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3 <br />TITLE PAGE: CERT Grant Application <br />Application Deadline: INCOMPLETE APPLICATIONS For Internal Use <br />Postmarked by midnight on WILL BE NOT BE <br />Friday May 30, 2003 CONSIDERED FORM <br />FUNDING <br />Please type or print in black ink <br />ORGANIZATION TYPE <br />501 (c) (3), municipal or county County Government <br />government <br />LEGAL APPLICANT INFORMATION <br />Organization Name: <br />Contact Person: <br />Employer ID Number: <br />Address: <br />Orange County Emergency Management <br />Nick Waters <br />56-6000327 <br />P.O. Box 8181 <br />City Hillsborough State NC Zip 27278 <br />Phone 919-968-2050 Fax 919-968-4066 <br />E-mail nwaters@co.orange.nc.us <br />Budget <br />Contractual Services: <br />Travel: <br />Equipment: <br />Supplies/Other Operating Expenses <br />Total Grant Funds Requested <br />$0 <br />$0 <br />$600.00 <br />$9,400.00 <br />$10,000.00 <br />PROPOSED PROGRAM YEAR <br />Beginning Date 5/13/03 Ending Date December 31, 2003 <br />Certification (required) <br />Name: Nick Waters <br />(print) <br />Title Emergency Management Director <br />Signature <br />Phone 919-968-2050 Date <br />PLEASE ATTACH 501(C)(3) or 501(C)(6) DOCUMENTATION TO THIS SHEET. <br />3 <br />