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DocuSign Envelope ID: E9553E7D-3748-4C37-A9D7-602D42934ACC 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: Public Gallery of Carrboro <br /> Applicant Organization's Physical Address: 300-G East Main St.; Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 300-G East Main St.; Carrboro, NC 27510 <br /> Applicant Organization's Web Address: www.wcomfm.org <br /> Executive Director: WCOM is all volunteer. Art Menius is chairman of the board of directors <br /> Telephone Number: 919-675-2787 E-Mail: art@artmenius.com <br /> DUNS Number: 133894746 <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: General Operating Support <br /> Project/Program Primary Contact and Title: Art Menius, Chairman of the Board <br /> Telephone Number: 919-675-2787 E-Mail: art@artmenius.com <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $ 18003.00 Total Amount of Funds Requested: $2000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): General Operating support of non-profit <br /> community radio programming, training of community radio hosts, replacement and maintenance of <br /> broadcast and production equipment. <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 /> El HOME CHDO (OC) $ ❑ Grant [' Loan <br /> ❑ HOME Other (OC) $ ❑ Grant ❑ Loan <br /> X❑ Human Services: XX❑ Carrboro $1000 ❑ Chapel Hill $0 XX❑ Orange County $1000 <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: No Executive Director N/A <br /> Executive Director Date <br /> Signature: January 22, 2016 <br /> Board Chairperson Date <br /> Main Application 5/25/2016 10:00:47 AM .. g 3 of 20 <br />