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3 <br />Section 11.0 <br />GRANT APPLICATION FORM <br />General Information <br />Legal Name of Applicant Organization: orange County <br />Name and Title of Authorized Signer for Applicant Organization: Laura Blackmon, County Manager <br />Mailing Address: P.O. Bow 8181 <br />City: Hillsborough State: NC County Orange Zip: 27278 <br />Street Address: • 200 • S. Cameron Street <br />City: Hillsborough State: NC County Orange - Zip: 27278 <br />Phone: 919-245-2300 Fax: 919-644-3004 <br />e-Mail: lblackmon@co.orange.nc.us <br />Federal Tax ID Number: 56-6000327 <br />Total Amount of Funding Being Requested under this Application: $ 3 , 949.45 <br />*Name of PEG Channel for which Funding is Being Sought: 1 <br />Total Amount of Funding Being Requested for this Channel: $ 3 , 949.45 <br />Type of Programming Offered by this Channel (P,E and/or G): G <br />Street Address: 2501 Homestead Road <br />City: Chapel Hill State:NC County. Orange Zip: 27514 <br />Phone: - Fax: - <br />If this is a °Gshared" channel, please list the other local governments which share operations <br />or programming with this channel: Not shared <br />Name and Title of Manager or Project Contact at PEG Channel: Gwen Harvey <br />Street Address: 200 South Cameron Street <br />City: <br />Hillsborough State: NC <br />County Orange <br />Zip: 27278 <br />Phone: 919-245-230? Fax: 919-644-3004 e-Mail: gharvey@co.orange.nc.us <br />~If regrcesting funding for rnzrltiple chmznels, please attach additim:al pages to this <br />Application Foruz and list complete inforruatiorz for all charnels for which fundizzg is being <br />sought under tl:is Application. <br />10-12-07 <br />