Orange County NC Website
FOR THE APPLICANT: <br />l~ G ~ ^ BY: !. <br />Date Signature <br />,~G~Cpd° 3 Z7 Kenneth T. Chavious <br />Applicant's Federal Tax LD. Typed Narne <br />Number (required) <br />Finance Director <br />Title <br />Date <br />FOR THE STATE: <br />BY: <br />Signature <br />Typed Name <br />Title <br />a ~~irwed 2/8/02 Pagc 4 of 7 Rev. 06(~ I <br />