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DocuSign Envelope ID:*An08reu~^0C3-4n0C-9r07-9ooC08r8C1ne i A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires separate <br /> ) Applicant Contact Information <br /> Applicant Organization's Legal Name: Farmer Foodshare <br /> Applicant Organization's Physical Address: 902 N. Mangum St. Durhenn, NC 27701 <br /> Applicant Organization's Mailing Address: P.O. Box 2873. Chapel Hi||, NC 27515 <br /> Applicant Organization's Web Address: www.farmerfoodshare.org <br /> Executive Director: Gini Bell <br /> Telephone Number: 819.300.6358 E-Mail: ginifornnerfnodshmre.org <br /> DUNS Number: 04-707-5380 <br /> (Dun & Bradotraet. |no. providosthionunoberetnoohargo. anditisrequiredforFedera} fundinU /eoipiento) <br /> b) Project/Program Contact Information <br /> Project/Program Name: Donation Station/POP Market <br /> Project/Program Primary Contact and Title: Katy Phillips <br /> Telephone Number: 918.381.0671 E-Mail: katy@fornnerfoodshare.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $ Total Amount of Funds Requested: $10.000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funds will support two programs in <br /> Orange County that support small, local farmers and supply fresh, healthy food to area hunger relief <br /> agencies. <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for each funding source. 'The Participating Jurisdiction reserves the right to <br /> fund p jects from any funding source, subject to e and funding constraints. <br /> [� <br /> C[>B(� Non-(�onatrun{ion (CH) $ [l�� Gnont �� Loan <br /> CDBG Construction (CH) Fl�� Grant F��� Loan <br /> HOME CHDO (00) 0 Grant 111 Loan <br /> U <br /> HOME Other (0C) U Grant 0 Loan <br /> xr_11 Human Services: x[l Carrboro $2.500 n0 Chapel Hill $5.000 x0 Orange <br /> County $250O <br /> d) 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 /> • <br /> - ^/ ' <br /> Signature: ��'�~. � __/���`' ),/� <br /> ()Executive Director �� ' Date ~ <br /> v~' <br /> Signature: " 1/25/2016 <br /> Board Chairperson Date <br /> Main Application 2/4/2016 9:38:02 AM <br />