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DocuSign Envelope ID: 1381F24A- F27B- 438F- AC45- 7A16015EA606 = xhlblt A: <br />Provider's Outside Agency Application <br />1. COVER PAGE <br />a) Applicant Contact Information <br />Applicant Organization's Legal Name: Big Brothers Big Sisters of the Triangle, Inc. <br />Applicant Organization's Physical Address: 808 Aviation Parkway, Suite 900 <br />Morrisville. NC 27560 <br />Applicant Organization's Mailing Address: SAME AS ABOVE <br />Applicant Organization's Web Address: www.bigstri.org <br />Executive Director: Erin Callahan <br />Telephone Number: 919 - 850 -9772 E -Mail: ecallahan @bbbstri.org <br />Tax ID Number: 56- 2109717 <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 />Program <br />Carrboro <br />Chapel <br />Orange <br />County - <br />Total <br />- HS <br />Hill - <br />HS <br />HS <br />The funds we are requesting are in support <br />of our two core mentoring programs — <br />Community -Based and Site -Based <br />Mentoring. These programs serve at -risk <br />children ages six to 14 throughout Chapel <br />Hill, Carrboro, and all of Orange County. <br />$5,000 <br />$10,000 <br />$10,000 <br />$25,000 <br />Totals <br />$5,000 <br />$10,000 <br />$10,000 <br />$25,000 <br />c) To the best of my knowledge and belief all information and data in this <br />application is true and current. The document has been duly authorized by the <br />governing board of the applicant. <br />AGENCY INFORMATION 1/18/2018 7:54:45 PM Page 8 of 29 <br />