Orange County NC Website
Browse       Search
Exhibit 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 Rape Crisis Center <br /> Applicant Organization's Physical Address: 1506 E. Franklin Street, Ste 302, Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: P.O. Box 4722, Chapel Hill, NC 27515 <br /> Applicant Organization's Web Address: ocrcc.org <br /> Executive Director: Alyson Culin <br /> Telephone Number: 919-968-4647 E-Mail: alyson(oocrcc.org <br /> DUNS Number: 835160862 <br /> b) Project/Program Contact Information <br /> (i) Project/Program Name: Client Services <br /> (ii) Project/Program Name: Community Education <br /> Project/Program Primary Contact and Title: Alvson Culin, Interim Executive Director <br /> c) Funding Request Identification <br /> (i)Total Project/Program Cost: $349,572.50 <br /> (ii)Total Project/Program Cost: $349,572.50 <br /> Total Amount of Funds Requested: $74,000 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): <br /> Provide 24-hour crisis intervention services for survivors of sexual violence. Provide community <br /> education, training, and advocacy on sexual assault prevention and response, including programs <br /> in Chapel Hill-Carrboro City Schools, Orange County Schools, and independent schools. <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 $12,000 ® Chapel Hill $27,000 ® Orange County$35,000 <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: LuQ..�-V. t ! 2 5/1 (o <br /> Exec D' a Date / <br /> Signature: <br /> B 94q 4KdtKp er on Date <br />