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• <br /> ACTION Form A•1421 OMB No. 3001-0()9a Expires:7/30/90 <br /> (Rev.7-e� For ACTION use only: <br /> VISTA PROJECT APPLICATION DATE RECEIVED: <br /> PAC IECT NO. <br /> BASIC HUMAN NEEDS AREA(S) <br /> 1.APPLICANT ORGANIZATION <br /> NAME <br /> 7.Total number of VISTA Volunteers requested 2 <br /> Orange County <br /> ADDRESS <br /> 8.Name each county in which Volunteers will serve — <br /> P.O Box 8181 <br /> CITY [STATE 1zpcoD E - Oran e <br /> Hillsborough L N.C. 27278 <br /> AREA CODE TELEPHONE NO. Terms and Conditions: If your organization is approved <br /> (919) 732-8181 as a VISTA Sponsor,your organization must agree to <br /> AGENCY DIRECTOR NAME <br /> assume responsibility in the community(ies)served for <br /> John Link, Jr. the development, implementation,and management of <br /> TITLE the VISTA Volunteer activities and the projects in which <br /> County Manager they serve. The undersigned accept the obligation to <br /> 2. PROJECT DIRECTOR - comply with statutes and regulations,policies,and the <br /> NAME terms and conditions pertinent to this program. <br /> Jerry M. Passmore The applicant organization must comply with the attached <br /> TITLE <br /> Department on Aging Director Assurances,page 13, if requested assistance is approved. <br /> ADDRESS Mewl?fro above) The undersigned further certify that the data in this <br /> application are true and correct and that the filing of this <br /> CITY STATE I.zp CODE application has been duly authorized by the governing <br /> body of the applicant organization. <br /> AREA CODE TELEPHONE NO. <br /> Applicants Certification Regarding intergovernmental <br /> 3.TYPE OF ORGANIZATION Review Under Executive Order 12372: If you are unsure, <br /> check with the ACTION State Office. <br /> A-State H-Community Action Agency <br /> ❑ Yes, this application was made available to <br /> B-Interstate I-Higher Educational Institutions <br /> the State Executive Order 12372 Process <br /> C-Substate District J-Indian Tribe for review on: <br /> D•County K•Other(Specify) <br /> E-City State Application Identifier No. (assigned <br /> F-School District by State) <br /> G-Special Purpose District • ENTER APPROPRIATE LETTER D <br /> ❑ No, Program is not covered by E.O. 12372, <br /> or <br /> 4. Was your organization previously a VISTA Sponsor? YES® NO❑ <br /> I yes,specify <br /> El No, Program has not been selected by <br /> If <br /> y P fy year(s)and number of vohmteer(s): State for review. <br /> — 1984-86 — One Volunteer <br /> S.Was your organization previously assigned VISTA Volunteer(s)? SIGNATURES:(Original signatures in blue ink <br /> required) .- <br /> YES© NO n a.SIGNATURE OF ORGAN1ZATION/AGENCY DIRECTOR <br /> If yes,specify year(s)and number of volunteer(s): <br /> 1984-86 — One Volunteer DATE <br /> 6.Congressional District Number(s): b.SGNATURE OF GOVERNING BODY CHAIRPERSON(,r igorrabiej <br /> a.of Sponsor Fourth <br /> b.of VISTA Project Sites Fourth f]47E <br /> Page 3 <br />