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DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued <br /> Provider's Outside Agency Application <br /> MAIN APPLICATION <br /> 1 1. COVER PAGE (Each program requires a separate application.) j <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name The Hillsborough Historic CornmissiorL Inc. <br /> Applicant Organization's Physical Address: 319 N Churton St Hillsborough NC 27282 <br /> Applicant Organization's Mailing Address: PO Box 922 Hillsborough NC 27282 <br /> Applicant Organization's Web Address: wvyw.burwellschool,org <br /> Executive Director: Kate Faherty <br /> Telephone Number: 919-732-7451 E-Mail: directorAburwellsohogrorg <br /> DUNS Number: 141818208 <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. The Burwell School Historic Site Visitor Services <br /> Project/Program Primary Contact and Title: Kate Faherty - Executive Director <br /> Telephone Number: 919-732-7451 E-Mail: director@burwellschooLorg <br /> c) Funding Request Identification <br /> 5 7, 0 <br /> Total Project/Program Cost: i$4501.0 Total Arnounl lot' Funds Requested:44-31411 f ,r , <br /> Proposed Use of Funds Requested (2-3 Line Maximum): The HCC proposes to strengthen & ik5./f7:1 <br /> expand visitor svcs @ the Burwell & to improve the walkability & safety for all visitors on property <br /> Please check all types, sources, and amounts of funding being requested. You must submit an <br /> application package for ea c 13 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 7 Loan <br /> — CDBG Construction (CH) $ E Grant E Loan <br /> r HOME CHDO (OC) $ Grant 7 Loan <br /> 0 HOME Other (OC) $ _ Grant Loan <br /> _ I Fltinian Se Iry ces: Er (ftrrboro $ E Chapel HOD 3 [iTi Orange County <br /> IF- II, <br /> d) To the best of 11,y knowledge 4,nd b,Llief all information and data in this applicatha'n ig , 0 ) <br /> true and current. The document has been duly authorized by the governing board of the 5,y0 <br /> applicant. <br /> Signature: -75/ ,...,„ <br /> _.7,,,, / cr"- ,.., <br /> x-C-dtive Director -7/:"""/---/..,„„, <br /> e/7 <br /> 1 Date //,,: <br /> < "/A97/,> <br /> '3.,...arcl Chairperson Date <br /> Main Application 1/24/2016 7:18:02 PM <br />