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DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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: Triangle Bikeworks <br /> Applicant Organization's Physical Address: 115 W. Main Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: P.O. Box 17202 Chapel Hill, NC 27514 <br /> Applicant Organization's Web Address: http://trianglebikeworks.org <br /> Executive Director: Kevin Hicks <br /> Telephone Number: 919-949-3359 E-Mail: kevinatrianglebikes.org <br /> DUNS Number: <br /> (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br /> b) Proiect/Proqram Contact Information <br /> Project/Program Name: Spoke'n Revolutions Youth Cycling <br /> Project/Program Primary Contact and Title: Kevin Hicks <br /> Telephone Number: 919-949-3359 E-Mail: kevin( trianglebikes.orq <br /> c) Funding Request Identification <br /> Total Project/Program Cost: $15,000Total Amount of Funds Requested: $7,500 <br /> Proposed Use of Funds Requested (2-3 Line Maximum): 2017 summer tour cycling sections of the <br /> Trail of Tears <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) $ 0 Grant 0 Loan <br /> LI CDBG Construction (CH) 0 Grant 0 Loan <br /> 10 HOME CHDO (OC) El Grant LI Loan <br /> 0 HOME Other(OC) 0 Grant 0 Loan <br /> LI Human Services: 4, Carrboro $3250 I Chapel Hill $3250 Orange County $1000 <br /> d) To the best of my knowledge and belief all information and data in this application is <br /> true an• rrent. The document has been duly authorized by the governing board of the <br /> appli,ant. <br /> Signature: <br /> ,-9/ <br /> th/ Air Aw- <br /> D- <br /> Signature: pOlo. Z q <br /> ard Chairperson Date <br /> Main Application 1/24/2016 2:55:18 PM Page 3 of 20 <br />