Orange County NC Website
Browse       Search
DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 Exhibit A <br /> Provider's Outside Agency Application <br /> APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY <br /> Rece v d By <br /> Agency: Chapel Hill and Carrboro Human Rights Center e t 'uai ` — <br /> 1 <br /> Complete t 'V/IN <br /> Program: Immigrant and Refugee Community Partnership <br /> 1. Cover Page a. 0Applicant Contact Information <br /> b. 0 Project/Program Contact Information <br /> c. 0 Funding Requests Identified <br /> d. 0 Signed Application Cover Page <br /> 2. Agency a. 0 Agency's Years in operation 24 CFR 570.506, <br /> Information - b. 0 Agency's Purpose/Mission 570.507, 570.610; 24 <br /> c. 0 Agency's Types of Services Provided CFR Parts 84 or 85 <br /> d. 0 Agency's Experience <br /> e. 0 Other Pertinent Information <br /> 3. Program/ a. 0 Type of Application and Program Identified 24 CFR 570.200(a), <br /> Project b. 0 Summary of Program 570.201-570. 208, <br /> Information - c. 0 Description of Identified Need 507.503 <br /> (for each d. 0 Description of Population to be Served <br /> program/ <br /> project for e. 0 Activity Manager and Location Description <br /> which funding f. Activity Implementation Timeline <br /> is requested) g. 0 Agency Collaboration <br /> h. 0 Describe Impact of Reduced/No Allocation <br /> i. 0 Other Pertinent Information <br /> j. 0 Complete Target Population/Beneficiary Chart <br /> k. 0 Complete Schedule of Positions <br /> I. 0 Signed Conflict of Interest Disclosure <br /> m. 0 Complete Work Statement <br /> 1 I II':' c <br />