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DocuSign Envelope ID: 5BF9183D-3BD5-4FD7-80DE-F437539D2E9F 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 Historicaj Foundation of Hillsborough & Orange County <br /> Applicant Organization's Physical Address: 201 N. Churton Street, Hillsborough NC 27278 <br /> Applicant Organization's Mailing Address: 201 N. Churton Street Hillsborough NC 27278 <br /> Applicant Organization's Web Address: www.orangenchistory.org <br /> Executive Director: Candace Midgett <br /> Telephone Number: (919) 732-2201 E-Mail: director@orangenchistory.prg <br /> DUNS Number: 931145098 <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Prpject/Program Contact Information <br /> Project/Program Name: Orange County,.Historical Museum Heritage Education Programs, <br /> Community Workshops, Exhibits, Collections <br /> Project/Program Primary Contact and Title: Candace Midgett <br /> Telephone Number: (919) 732-2201 E-Mail: director@orangenchistory.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $31,787.00Total Amount of Funds Requested: sg,o_oo <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Materials costs, transportation,_personnel <br /> expenses for Heritage Education outreach to OC K-12 students;_public education via museum <br /> exhibitions; preservation/collections care/research efforts to benefit museum stakeholders. <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) $ E] Grant 111 Loan <br /> Li CDBG Construction (CH) El Grant n Loan <br /> El HOME CHDO $ ID Grant 11 Loan <br /> LI HOME Other Grant L Loan <br /> Human Services: OCarrboro $ Hill $ I Orange County $6,600 <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: ■ <br /> Excutive Director Date <br /> Signature: ( <br /> Board airpeson Date '77 <br /> Main Application 1/25/2016 1:35:10 PM <br />