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7 <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: <br /> Applicant Organization's Physical Address: <br /> Applicant Organization's Mailing Address: <br /> Applicant Organization's Web Address: <br /> Executive Director: <br /> Telephone Number: E-Mail: <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County-HS <br /> Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Totals <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> Board Chairperson Date <br /> AGENCY INFORMATION Page 6 of 17 <br />