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2 . <br /> OMIT No.3001.0098 Expires:7/30/90 <br /> — <br /> ACTION Form A.;421 For ACTION use only: <br /> d <br /> (Rev.7.87) DATE RECEIVED: 4/13/88 <br /> VISTA PROJECT APPLICATION PROJECT NO. <br /> • BASIC HUMAN NEEDS AREANS) <br /> 1.APPU ANTARGANIZATION <br /> w►ua T.Total number of VISTA Volunteers requested 1 <br /> Orange County <br /> woRESS 8.Name each county in which Volunteers will serve <br /> P.O Box 8181 Orange <br /> CITY STATE 2P CODE <br /> Hillsborough N.C. 27278 <br /> AREA CODE TELEPHONE NO. Terms and Conditions: If your organization is approved <br /> (919) 732-8181 as a VISTA Sponsor,your organization must agree to <br /> AGENCY DIRECTOR NAME assume responsibility in the community(ies)served for <br /> .. John Link, J r. the development.implementation,and management of <br /> ME the VISTA Volunteer activities and the projects in which <br /> County M a n a a e r they serve. The undersigned accept the obligation to <br /> --- <br /> 2.PROJECT DIRECTOR comply with statutes and regulations,policies,and the • <br /> . terms and conditions pertinent to this program. <br /> NAME <br /> Jerry M. P a s s m o r e The applicant organization must comply with the attached,, <br /> ME Assurances.page 13,if requested assistance is approved. <br /> Department on Aging Director The undersigned further certify that the data in this <br /> Aomess lraati.mAom.00. / application are tare and correct and that the filing of this <br /> 300 West Tryon Street application has been duly authorized by the governing <br /> CITY STATE: zP tz7OE body of the applicant organization. <br /> Hillsborough NC J 27278 <br /> AREA CODE TELEPHONE AV. Applicant's Certif cation Regarding Intergovernmental <br /> (919) 732-8181 E x t 280 Review Under Executive Order 12372: If you are unsure, <br /> 3.TYPE OF ORGANIZATION check with the ACTION State Office. <br /> A•State H-Community Action Agency ❑ Yes, this application was made available to <br /> 8-Interstate t-Higher Educational institutions the State Executive Order 12372 Process <br /> ..C•Substate District J-Inden Tribe for review on:• <br /> D-County R-Ot'er(Specify) State Application Identifier No. (assigned <br /> E•City - by State) <br /> F•School District <br /> - G-Spewl Purpose District • ENTER APPROPRIATE LETTER r a No, Program is not covered by E.O. 12372, <br /> or <br /> 4. Was your organization previously a VISTA Sponsor? YES E No❑ ❑ No, Program has not been selected by <br /> It yea,specify years)and number of whnteer(s): State for review. <br /> 1984-8Et — One } lunteer <br /> 5.Was your erganitation previously assigned VISTA Vohxite:Ms)? SIGNATURES:(Original signatures in blue ink roc:eked) <br /> YES al NOD a.stemIURE OF t]i NrAS> rA:CO+CY '/• <br /> dyes.specify years)and number of vokmlaer(s): _ John M: _ irk, r, unto Manager <br /> 1984-86 — One VV]junt ,r twIE: <br /> t, <br /> 5.Congressional District Number(s): b.so a i LNG Boor 0 <br /> a,� Fourth GL.c //�<.-� - <br /> --- <br /> Sponsor. <br /> • b.of VISTA Proiect Silas Fourth <br /> an 2 <br /> Shirley Ma r, Chr. County Commissioners <br /> • . . . ...... , .. Page 3 <br />