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a~ <br />Part I -Standard HWTFC Grant Application <br />Applicant Oraanization(sl <br />Lead Applicant Organization/Fiscal Agent <br />Orgazrization Name Orange County Health Department (OCHD) <br />Address 1 300 West Tryon Street <br />Address 2 <br />City <br />County (office location) <br />ZIP Code <br />Organization Director°(s) <br />Title(s) <br />Website Address <br />Federal Employer ID # <br />Hillsborough <br />Orange <br />27278 <br />Rosemazy Summers <br />MPH, DrPH <br />www.co.orange. nc.us/health <br />56-6000327 <br />Grant Applicant and Grant Administrator <br />Application prepazed by Matt Streng, MPH <br />Title Youth Tobacco-Use Program Manager <br />Phone <br />Fax <br />Email address <br />Grant Administrator* <br />Title <br />Phone <br />Fax <br />Email address <br />919-245-2424 <br />919-644-3007 <br />mstreng@co.orange.nc.us <br />Letitia Burns <br />Business Officer - OCHD <br />919-245-2410 <br />9I9-644-3007 <br />lburns@co.orange.nc.us <br />Grant Administrator will be the principal contact point following award <br />Grantee Status (check only one) <br />^ New HWTFC grant applicant <br />® Current HWTFC grantee <br />Project Type (check only one) Note: Proposals that provide services in rnore than one <br />programmatic category should select die one project type category below that is most <br />r°epresentative of their overall project. <br />® Community/School Project <br />^ Special Project <br />^ Priority Population Project <br />Total Budget Request: $ $289,130.00 <br />