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. 40/../14, 17'r <br /> OMB No.3001-0098 Expires:7/30/90 <br /> ACTION Form A-1421 For ACTION use only: <br /> (Rev.7-87) _ y <br /> VISTA PROJECT APPLICATION BATE RECEIVEb: <br /> PROJECT O. <br /> BASIC Hl1MAN NEEbS AREAS) <br /> I.APPLICANT ORGANIZATION <br /> NAME 7.Total number of VISTA Volunteers requested 2 <br /> Orange County <br /> ADDRESS 8.Name each county in which Volunteers will serve <br /> P.O Box 8181 <br /> CITY STATE ZP CODE O r a n g e <br /> Hillsborough 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 - 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 /> TITLE Jerry M. P a s s m o r e The applicant organization must comply with the attached <br /> Assurances,page 13, if requested assistance is approved. <br /> Department on Aging D i r e c t o r The undersigned further certify that the data in this <br /> ADDRESS(II Moroni from above) application are true and correct and that the filing of this <br /> application has been duly authorized by the governing <br /> CRY STATE ZIP CODE body of the applicant organization. <br /> AREA CODE TELEPHONE NO. <br /> Applicant's Certification Regarding Intergovernmental <br /> Review Under Executive Order 12372: If you are unsure, <br /> 3.TYPE OF ORGANIZATION check with the ACTION State Office. <br /> A-State H•Community Action Agency [] Yes, this application was made available to <br /> 13.Interstate I-Higher Educational Institutions the State Executive Order 12372 Process <br /> C-Substate District J-Indian Tribe for review on: <br /> t-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 C] No, Program is not covered by E.Q. 12372, <br /> or <br /> 4. Was your organization previously a VISTA Sponsor? YES® NO[] <br /> [] No, Program has not been selected by <br /> If yes,specify year(s)and number of volunteer(s): State for review. <br /> 1984-86 — One Volunteer <br /> 5.Was your organization previously assigned VISTA Volunteer(s)? SIGNATURES: (Original signatures in blue ink required) <br /> YES© Note e.SIGNATURE OR IZATION/AENCY (RECTOR <br /> M yes,specify year(s)and number of volunteer(s): • <br /> 1; "L ' <br /> 1984-86 One Volunteer DAM .i <br /> 6.Congressional District Number(s): b.siGNATyPE• GOVE IIMG BODY CHAT RSON tlr W <br /> a.of Sponsor Fourth / <br /> DATE <br /> b.of VISTA Project Sites Fourth . <br /> Page 3 <br />