Orange County NC Website
Browse       Search
DocuSign Envelope ID:E522BFFC-A634-4A11-A162-195A3BE957A4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Duke University Health System, Inc.d/b/a Duke HomeCare&Hospice <br /> Applicant Organization's Physical Address: 4321 Medical Park Drive, Suite 101, Durham, NC 27704 <br /> Applicant Organization's Mailing Address: 4321 Medical Park Drive,Suite 101,Durham, NC 27704 <br /> Applicant Organization's Web Address: https://dhch.duhs.duke.edu <br /> Executive Director: Belle Starr Browning <br /> Telephone Number: 919.620.3853 E-Mail: starr.browning@duke.edu <br /> Tax ID Number: <br /> b) Funding Request <br /> List all FY17-18 Human Services (HS) Funding Being Requested — <br /> For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> Program Carrboro Chapel Orange Total <br /> - HS Hill - HS County-HS <br /> Duke Hospice Bereavement Services will use the $3,800 $3,200 $1,200 $8,200 <br /> funds to offset the costs of providing care to grieving <br /> individuals in Chapel Hill, Carrboro and Orange <br /> County. We continue to offer our services at no cost <br /> to any individual in the area who request our support. <br /> Totals $3,800 $3,200 $1,200 $8,200 <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 /> „..am <br /> Signature: - -puck <br /> Executive Director Date <br /> Signature: Oi/t\ 2-tr <br /> Board Chairperson Date <br /> DO NOT SUBMIT THIS PAGE 1/25/2017 11:08:11 AM Page I of 6 <br />