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MAIN APPLICATION <br />1. COVER PAGE (Each program requires a separate application.) <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Planned Parenthood South Atlantic <br />Applicant Organization's Physical Address: 1765 Dobbins Dr, Chapel Hill, NC 27514 <br />Applicant Organization's Mailing Address: 1765 Dobbins Dr, Chapel Hill, NC 27514 <br />Applicant Organization's Web Address: <br />Executive Director: <br />Telephone Number: 919 - 833 -7526 x6140 <br />www.ppsat.org <br />Jenny Black <br />E -Mail: jenny.blackna212sat.org <br />DUNS Number: 110314622 <br />(Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) <br />b) Project /Program Contact Information <br />Project/Program Name: Sexual Health Education and Outreach <br />Project/Program Primary Contact and Title: Lisa Garland, Community Health Educator <br />Telephone Number: 919 - 818 -7760 <br />c) Funding Request Identification <br />E -Mail: lisa. arg land&a 1212sat.org <br />Total Project /Program Cost: $ 37,886Total Amount of Funds Requested: $23,500 <br />Proposed Use of Funds Requested (2 -3 Line Maximum): Funds will be used to su1212ort the salary <br />costs of a Community Health Educator in Orange County, who will conduct programs intended to <br />reduce the rates of unintended pregnancy and sexually transmitted infection in the Orange County, <br />Please check all types, sources, and amounts of funding being requested. You must submit an <br />application package for each funding source. *The Participating Jurisdiction reserves the right to <br />fund projects from any funding source, subject to eligibility and funding constraints. <br />❑ CDBG Non - Construction (CH) $ ❑ Grant ❑ Loan <br />❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan <br />❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan <br />❑ HOME Other (OC) $ ❑ Grant ❑ Loan <br />0 Human Services: ❑ Carrboro $1,000 ❑ Chapel Hill $2,500 ❑ Orange County $20,000 <br />d) 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 />Signature: <br />Xard Chairperson <br />MVh Application <br />1/21/2016 <br />Date <br />1/21/2016 <br />Date <br />1/21/2016 18:35:26 a1 /p1 Page 3 of 24 <br />