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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: The Arc of the Triangle Inc. <br /> Applicant Organization's Physical Address: 1709 Legion Road, Suite 100 Chapel Hill NC 27517 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.arctriangle.org <br /> Executive Director: Robin Baker <br /> Telephone Number: 919 942 5119 E-Mail: rbaker(a)-arctriangle.org <br /> DUNS Number: 95-638-8177 <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Proiect/Program Contact Information <br /> Project/Program Name: Social and Volunteer Opportunities <br /> Project/Program Primary Contact and Title: Susan Chandler, Assistant Director of Volunteer and <br /> Social Programs <br /> Telephone Number: 919 942 5119 xt 111 E-Mail: schandleraarctriangle.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $23,000.00 Total Amount of Funds Requested: $23,000.00 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): <br /> People with Intellectual and Developmental Disabilities (IDD) often lead lives that have limited <br /> opportunities for social inclusion and participation. Restricted and sedentary lifestyles significantly <br /> reduce quality of life. Funding for this program will go directly to coordinate and monitor activities <br /> that enable people with IDD become engaged with the community through the use of community <br /> volunteers, spaces and resources. <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 ❑ Loan <br /> ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan <br /> ❑ HOME CHDO $ ❑ Grant ❑ Loan <br /> ❑ HOME Other $ ❑ Grant ❑ Loan <br /> x Human Services: x Carrboro $5,000.00 x Chapel Hill $12,000.00 x Orange County $6,000.00 <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 /> Main Application 5/25/2016 10:10:25 AM Page 3 of 24 <br />