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AGENCY INFORMATION 11/13/2017 11:44:58 AM Page 8 of 20 <br /> <br />1. COVER PAGE <br /> <br />a) Applicant Contact Information <br /> <br />Applicant Organization’s Legal Name: <br /> <br />Applicant Organization’s Physical Address: <br /> <br />Applicant Organization’s Mailing Address: <br /> <br />Applicant Organization’s Web Address: <br /> <br />Executive Director: <br /> <br />Telephone Number: E-Mail: <br /> <br />Tax ID Number: <br /> <br />b) Funding Request <br />List all FY18-19 Human Services (HS) Funding Being Requested – <br />For All Programs) and the Proposed Use of Funds (2-3 lines or less) <br /> <br />Program Carrboro <br />- HS <br />Chapel <br />Hill - HS <br />Orange <br />County-HS <br />Total <br />Ex. Youth Afterschool Program <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$10,000 $15,000 $5,000 $30,000 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Totals <br /> <br /> <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 /> <br /> <br />Signature: <br /> Executive Director Date <br /> <br /> <br />Signature: <br /> Board Chairperson Date <br /> <br /> <br />9