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DocuSign Envelope ID: 10F0B4DA-C8B5-4AB3-9AFA-939AE0010B18 (HIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> -- 1,,, COVE mt PAGE <br /> a) tili,,plicant Contact information, <br /> Applicant Organization's Legal Name: The Marian Cheek Jackson Center for Saving and <br /> , Melding Histca_ <br /> Applicant Organization's Physical Andress: 512W, Riosernaly Street. Clia2e1Hill, NC 27516 <br /> Applicant Organization's Mailing Address: Same as above <br /> Applicant Organization's Web Address: www iacksonicenter.ipfc <br /> Executive Director: Della Pollock <br /> Tel Number: _(„„9,19 960-1670 E-Mail. nudscoAjacksoncentecinfo <br /> Tax ID Number: <br /> h) Fu ding Request <br /> List JH FYI 7-18 Human Services HS," Funding Being Requested - <br /> For Ali Prpkima) and the Prcnosed Use of Funds (24 lines or less) <br /> Program Carrboro Chapel Orange Intel <br /> - Hp Hin Hq ct, - !,,,is <br /> Learning Across Generations: Expansion of K-12 riivd1 $4,000 $6,000 $12, 600 $22, 500 <br /> rights education curriculum and audio irnmersQon program <br /> rooted in social justice work and yddth-ied activism <br /> CITS°; <br /> .. ..„, <br /> Totals L$4,000 r$6,000 $12, 50 22, 5(:)9_, <br /> c) To the best of my kno ledge and belief all information and data in this application is <br /> true and current. The gob/merit has been duly authorized by the doyen ing h curd of the <br /> 'spoils ,nt, <br /> / <br /> Signature: <br /> ex,/ <br /> , , ,, ,,' „/ / - _ <br /> F e f.itiv /rY.eector Date <br /> Signature: "9 21- '-,----------", <br /> Bo Chairperson ,,,,,K Date <br /> ii <br /> AGENCY INFORMATION 1/27/2017 3:01:18 PM <br />