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EXHIBIT 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: Orange County Living Wage <br /> Applicant Organization's Physical Address: 218 Lake Manor Rd., Chapel Hill, NC 27516-4321 <br /> Applicant Organization's Mailing Address: PO Box 1502, Carrboro, NC 27510-1502 <br /> Applicant Organization's Web Address: httpl lwww.orangecountylivingwage.org/ <br /> Executive Director Susan Romaine(Steering Committee and Board of Directors Chair) <br /> Telephone Number. 919-619-3408 E-Mail: susansmmaine @gmail.com <br /> DUNS Number. 942152575 <br /> (Dun& Bradstreet, Inc. provides this number at no charge,and it is required for Federal funding recipients.) <br /> b) Proiect/Prooram Contact Information <br /> Project/Program Name: Orange County Living Wage Certification Program <br /> Project/Program Primary Contact and Title: Susan Romain, Chair, Steering Committee and Board <br /> of Directors <br /> Telephone Number. 919-619-3408 E-Mail: susanromain @gmaii.com <br /> c) Funding Request Identification <br /> Total Project/Pmgram Cost: $24,850 Total Amount of Funds Requested: $16,750 <br /> Proposed Use of Funds Requested(2-3 Line Maximum): <br /> The funds will be used to hire a half-time administrative assistant to coordinate the major activities <br /> of the organization, thereby making possible the attainment of the goals specified for 2016-17 in <br /> section 3(m)of this application. <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 deserves the right to <br /> fund projects from any funding source, subject to eligibility and funding constraints. <br /> ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan <br /> ❑ CDBG Construction (CH) $ ❑Grant ❑ Loan <br /> ❑ HOME CHDO(OC) $ ❑Grant ❑ Loan <br /> ❑ HOME Other(OC) $ ❑Grant ❑ Loan <br /> "❑ Human Services: ❑ Carrboro$ []Chapel Hill$ "❑ Orange <br /> County <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 /> 6Aftin Ar%nlinftNnn 4mr%i,)nia 44.4x1.77 AAA D ., n n o f 7 7 <br />