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DocuSign Envelope ID: 913F749B-B9E8-4103-AF9D-A4296D01069E 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: Society for the Betterment of the Human Condition through <br /> the Training, Instruction and Propagation of Budo Karate (d.b.a. Ligo Doio of Budo Karate) <br /> Applicant Organization's Physical Address: 630 Weaver Dairy Road Chapel Hill NC 27514 <br /> Applicant Organization's Mailing Address: 2418 A Millwood Court Chapel Hill NC 27514 <br /> Applicant Organization's Web Address: www.ligodojo.com <br /> Executive Director: Nathan Liqo <br /> Telephone Number: 919-923-6915 E-Mail: nligohotmail.com <br /> DUNS Number: n/a <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Frolect/Proqram Contact Information <br /> Project/Program Name: Young Warriors Program <br /> Project/Program Primary Contact and Title: Nathan Ligo, Executive Director <br /> Telephone Number: 919-923-6915 E-Mail: nligohotmail.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $35,600 Total Amount of Funds Requested: $2,000 each from Chapel <br /> Hill, Carrboro, and Orange County: $6000 total <br /> Proposed Use of Funds Requested (2-3 Line Maximum): <br /> The Young Warriors program instills discipline, increases self-esteem, and physical and mental <br /> health in referred, disadvantaged youth through martial arts training. Funding allows youths to <br /> attend ten or more weeks of karate training, two or more times per week at our location. Grant <br /> funds help ensure a diverse training environment for youth and their families. <br /> Please check all types, sources, and amounts of funding being requested. <br /> I- CDBG Non-Construction (CH) $ El Grant El Loan <br /> El CDBG Construction (CH) $ El Grant D Loan <br /> E HOME CHDO (OC) $ El Grant 1:1 Loan <br /> E HOME Other(OC) E] Grant El Loan <br /> Z Human Services: Z Carrboro $2,000 Chapel Hill $2,000 E Orange County $2,000 <br /> d) To the best of my knowledge an telief all information and data in this application is <br /> true and currffit-ifhe documen has been duly authorized by the governing board of the <br /> oi <br /> applicant. ii .„ „, <br /> Signature: `-'7 ...,,c A.3.14-- j ---- I <br /> Exe„,rti,vepirectrt _ + Date ) <br /> Signature: 'tli '. L(*--(1.,Z-, ,_ 1 I 2:::,- <br /> Boatd Chairperson Date l <br /> Main Application 1/25/2016 10:16:09 AM Page 3 of 20 <br />