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DocuSign Envelope ID: 1BCF0634-CD89-4310-96E4-A32E6E1A91A6 <br /> PART 3: APPLICATION CHECKLIST <br /> APPLICATION C ECKL1ST <br /> Please compile in this order. Do no staple, bind, or put into individual folders or sleeves. Provide one copy, <br /> one skied, a 5 x 11 white paper A digital copy of the application is not necessary. <br /> X Applicalion Fowl including signatures <br /> X Narrative <br /> X Detailed Budget(if necessary) <br /> X Resumes of key artists and administrators involved in grant funded program(s) <br /> X Income and Expense statement for FYI 8-16 <br /> X Budget or year-to-date statement for FY16-17 <br /> X Budget for FY17-18 <br /> X Currenti;oard of Directors' list <br /> X Copy of IRS Tax Exemptn Letter, if appiicable <br /> X Sample programs, press, or other materials from this or similar past programs <br /> X liViork samples by artists), labeled with artists" name, title of work, date of work, produced in the last ihr e years: <br /> o Visual artists: CD, DVD„ or high resolution photographs la images per artist MAX),clearly labeled with <br /> dimensions and media and indicate top of Image <br /> O Dance or theater rtist: CD or .VD,or link to high-quallity online video(3-5 minutes) <br /> O Music and spoken word: CD , MP3 or link to higtioatiality online video(3-5 minutes) <br /> O Literary arts: Manuscript (10-15 pages)submitted .s pdf file or hard copy <br /> PART 4: CERTIFICATION <br /> We tindersiand that failure to respond to any or tite above items may adversely affect the consideration or this application. <br /> We certify that we are central. rid to the completion of the proposed firoject in compliance with fral requiromen all <br /> granting Free:i tires.Vie certify that the Inform: co cortalitod in this 41301111callx)n,tricincling aliments and annotating <br /> materiels,Is 1, 1 arid correct to the best of our knowledge, <br /> Printed of typed nrirrio., I Candace fondles*,executive(*rector,Onirreje County Histrielcal Museum <br /> Signature <br /> 111 <br /> „ . <br /> Elate: I May 31,2017 <br /> 1740;r1r04.54"4qt,t, AiTrigkeo-71,7„,, toolt.61:61041*go 4, f re410,111e0.1 <br /> „„e, h, POwi,14"" ti.'7,61twitr.gi t, , 4,1001/411,,' <br /> Print:d or typ:d name: Ernest Dollar.cbat . „Ilistottcal Foundation of Iliitiborough&Orange Co ly <br /> Sriature: 11111111111/ri <br /> '1111111, <br /> May 31,2017 <br /> r.19r (,,pf r <br />