Orange County NC Website
Browse       Search
DocuSign Envelope ID: E85EF868-A4BB-49ED-96E1-165F3DADBAE4 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Orange County ape Crisis Center <br /> Applicant Organization's Physical Address: 1506 E. Franklin Street, Suite 302 <br /> Chapel Hill, NC 27514 <br /> Applicant Organization's Mailing Address: PO Box 4722, Chapel Hill, NC 27515 <br /> Applicant Organization's Web Address: ocrcc.orq <br /> Executive Director: Alyson Culin <br /> Telephone Number: 919-968-4647 E-Mail: alysonocrec.orq <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding :eing Requested — <br /> For All Program's) and the Proposed Use of Funds (2-3 lines or less) <br /> Carrboro Chapel Orange I <br /> Program <br /> - <br /> - HS Hill -HS I Count -HS Total <br /> I Client Services: <br /> 24-hour crisis intervention services for survivors of <br /> $10,000 $20,000 $35,000 $65,000 <br /> sexual violence, their loved ones, and professionals <br /> who support them <br /> Community Education: <br /> Education programs, training, and advocacy on sexual <br /> violence prevention and response, including programs $10,000 $20,000 $35,000 $65,000 <br /> in Chapel Hill-Carrboro City Schools, Orange County <br /> Schools, and independent schools <br /> Totals $20,000 $40,000 $70,000 $130,000 <br /> c) To the best of my knowledge and belief all information and data in this application is <br /> true and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: , <br /> Executivel.Director Date <br /> / / <br /> Signature: I / 7, 1/.7) <br /> CKailWreon Date <br /> AGENCY INFORMATION 1/30/2017 5:14:05 PM Pn9e 2 u I 22 <br />