Orange County NC Website
Browse       Search
DocuSign Envelope ID: 535BB656- 53CF- 457A- 98B2- D73B9641501D XHIBIT A <br />PROVIDER'S OUTSIDE AGENCY APPLICATION <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Senior Care of Orange County, Inc. <br />Applicant Organization's Physical Address: 105 Meadowland Drive <br />,Hillsborough, NC 27278 <br />Applicant Organization's Mailing Address: 105 Meadowland Drive, Hillsborough, NC 27278 <br />Applicant Organization's Web Address: www.soltysdayhealth.org <br />Executive Director: Alvonia Baldwin <br />Telephone Number: 919- 245 -2017 <br />Tax ID Number: 56- 2460614 <br />E -Mail: albaldwin @oranc�ecountync.gov <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 <br />Carrboro <br />Chapel . <br />Hill - HS <br />Oran a <br />Coun -HS' <br />Total <br />- Hs <br />TheAdf�lt day Health Program, Opelatlons, <br />progxamrnt sppl[es anal days ofetvice fQT the; <br />"" z" 2 ✓ z-`'5 . <br />$'l 500 <br />�r ✓ <br />$2,500 <br />$40400 <br />Totals <br />$1,500 <br />$2,500 <br />$40100.0 <br />$44,000 <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 />Executive Director <br />Signature: W. � — <br />Board Chail erson <br />IJ2 :Z <br />Date <br />11-:17 % <br />Date <br />