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DocuSign Envelope ID: E8534F48-BEAD-4670-896E-4E8718B819E1 t A - continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1. COVER PAGE (Each program requires a separate application.) <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The ArtsCenter <br /> Applicant Organization's Physical Address: 300-G East Main St., Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: SAME <br /> Applicant Organization's Web Address: www.artscenterlive.org <br /> Executive Director: Daniel Y. Mayer <br /> Telephone Number: 919-929-2787x217 E-Mail: dmayer @artscenterlive.org <br /> DUNS Number: 029686396 <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Project/Program Contact Information <br /> Project/Program Name: The ArtsCenter's arts and education programs <br /> Project/Program Primary Contact and Title: Julie Tomkovick, Development Director <br /> Telephone Number: 919-929-2787x213 E-Mail: development@artscenterlive.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $1,627,741 Total Amount of Funds Requested: $45,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Support for ArtsCenter Educational Youth <br /> Pro•rams from Oran s e Count . here is a se iterate a.Oration for General Su**on of one ear of <br /> ArtsCenter Programs from the Town of Carrboro and Town of Chapel Hill.1 <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 projects from any funding source, subject to eligibility and funding constraints. <br /> ❑ CDBG Non-Construction (CH) $ ❑ Grant El Loan <br /> El CDBG Construction (CH) $ ❑ Grant El Loan <br /> L=l HOME CHDO $ ❑ Grant ❑ Loan <br /> HOME Other $ [' Grant ❑ Loan <br /> ® Human Services: ® Carrboro $20000 ® Chapel Hill $15000 ® Orange County $10000 <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 /> Signature M.. <br /> ;ecut° Directo Dat <br /> Signature: E4 l ( 1 1 <br /> :Toard r airperson D to <br /> Main Application 1/21/2016 4:03:32 PM Page 3 of 2 0 <br />