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DocuSign Envelope ID: CB0C1343-06EB-4BE7-9AF6-62EE77BD69FE 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: Planned Parenthood South Atlantic <br /> Applicant Organization's Physical Address: 1765 Dobbins Dr, Chapel Hill,NC 27514 <br /> Applicant Organization's Mailing Address: 1765 Dobbins Dr, Chapel Hill,NC 27514 <br /> Applicant Organization's Web Address: www.ppsat.org <br /> Executive Director: Jenny Black <br /> Telephone Number: 919-833-7526 x6140 E-Mail:jenny.black @ppsat.org <br /> DUNS Number: 110314622 <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: Sexual Health Education and Outreach <br /> Project/Program Primary Contact and Title: Lisa Garland, Community Health Educator <br /> Telephone Number: 919-818-7760 E-Mail: lisa.garland @ppsat.org <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $ 37.886Total Amount of Funds Requested: $23,500 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): Funds will be used to support the salary <br /> costs of a Community Health Educator in Orange County,who will conduct programs intended to <br /> reduce the rates of unintended pregnancy and sexually transmitted infection in the Orange County. <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 /> X Human Services: ,X Carrboro $1.000 x Chapel Hill $2.500 x Orange County $20.000 <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: 4 it.. l/ 1/21/2016 <br /> !j 4 -etor Date <br /> Signature: S4 1/21/2016 <br /> •ard Chairperson Date <br /> M ih Application 1/21/2016 18:35:26 a1/p1 Page 3 of 2 <br />