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000vSign Envelope ID:0eoour84-5EC0-4orr'e4F6-r480A1C3Ae13 =xhibit /\ <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> —'-- - — -- <br /> 1. COVER PAGE (Each program uires a separate app lication.) <br /> _-� <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: El Centro Hiapano. Inc <br /> Applicant Organization's Physical Address: 600 E, Main Street, Durham, NC 27701 <br /> Applicant Organizations Mailing Address: same as above <br /> Applicant Organization's Web Address: www.elcentconcorcJ <br /> Executive Director. pUarRoohaGoldberg <br /> Telephone Number:_1S19> 687'4035Ext. 43 E-Mail: proohmAe|cenhono.opq <br /> DUNS Number: 159206015 <br /> (Dun & Bradstreet, Inc. provides this number at no charge and it is required for Federal funding recipients.) <br /> b) Proect1Proqram Contact Information <br /> Project/Program Name: Center for Employment& Leadership Development <br /> Project/Program Primary Contact and Title: |dbeKl. PreeidenUCEQ <br /> Telephone Nomber1S19) 0G7'4835 Ext. 43 E'K8mi|: Qrocha@ nc�&rg <br /> c) Funding Request Identification <br /> � <br /> Tota Project/Program Cost: $$211,338 Total Amount of Funds Requested: $25.040 <br /> / <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Requesting funds to support activities <br /> through the Center for Employment and Leadership focused on outreach to workers/employers, <br /> ( kfo i i l b ■i � small and worker uuppodservices <br /> public workforce or r�et[on n� o � �oemen . ` <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 Jurisdictknnmroeo/eahhe right to <br /> fund projects from any funding oouo;e. oubkpc/ tmeliA/bJJvandfon/ingconntrai/ts. <br /> CDBG Non-Construction (CH) $ Grant E Loan <br /> CDF3G Construction (CH) $ |lGrant EI Loan <br /> HOME CHDD ((}C) $ �� <br /> Grant Loan <br /> El HOK8E Other({}{�) $ | Grant �] Loan <br /> EM ` ' <br /> X Human Services: x Carrboro $ 5,000 x Chapel Hill $L,500 x Orange County $12.54O <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 /> t <br /> app Ucon. <br /> Signature: W/ fiLW P-C)cLS 0( fc f( <br /> °= <br /> ' <br /> Director <br /> -~ Date <br /> Signature: 0 0 <br /> ( /2-.5 /J, <br /> Board Chairperson _ _ <br /> Date <br /> P 3 Q � 3 <br /> Main Application 1/25/2016 12:33:55 PM age <br />