Orange County NC Website
Browse       Search
DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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: Orange County Disability Awareness Council <br /> Applicant Organization's Physical Address: 503 West Franklin St., Chapel Hill, NC 27516 <br /> Applicant Organization's Mailing Address: 503 West Franklin St., Chapel Hill, NC 27516 <br /> Applicant Organization's Web Address: http://triangledac.org/ <br /> Executive Director: Timothy Miles <br /> Telephone Number: 919.245.4337 E-Mail: ocdac @orangecountync.gov <br /> DUNS Number: <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: Education and Training Resources for People with Disabilities <br /> Project/Program Primary Contact and Title: Timothy Miles, Director <br /> Telephone Number:919-245-4337 E-Mail: ocdac a(�orangecountvnc.gov <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $30000 Total Amount of Funds Requested: $30000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funding for as-needed basic operating <br /> expenses, ADA related workshop employment training, human interest projects, resources, <br /> supplies, staff training, computer support, travel and printing. <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 /> ❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan <br /> ❑ HOME Other(OC) $ ❑ Grant ❑ Loan <br /> ® Human Services: ® Carrboro $10000 ® Chapel Hill $10000 ►1 Orange County $10000 <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: Timoth L. Mile 2016 <br /> Executive Dire or Date <br /> Signature: L nn M. Shei ds January 20, 2016 <br /> Board Chat .- -on _.% /MAW 'ate <br /> Main Application +. x%12512016 3:59:43 PM Page 3 of 19 <br />