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DocuSign Envelope ID: 28872B9E- 993A- 44CA- 8A5E- OBDA1F6178CB <br />Exhibit A: Provider's Outside Agency Application <br />MAIN APPLICATION <br />1. COVER PAGE (Each program requires a separate <br />application.) <br />a) Applicant Contact information <br />Applicant Organization's Legal Name: Orange County Disability Awareness Council <br />Applicant Organization's Physical Address: 503 West Franklin St., Room 113, Chapel Hill, NC <br />27516 <br />Applicant Organization's Mailing Address: 5033 West Franklin St., Room 113, Chapel Hill, NC <br />27516 <br />Applicant Organization's Web Address: http: /Itriangledac.org/ <br />Executive Director: Timothy Miles <br />Telephone Number: 919.245.4337 E -Mail: ocdac@orangecountync.gov <br />DUNS Number: <br />(Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding <br />recipients.) <br />b) Project/Program Contact Information <br />Project/Program Name: Education and Training Resources for People with Disabilities <br />Project/Program Primary Contact and Title: Timothy Miles, Director <br />Telephone Number:919 -245-4337 <br />c) Funding Request Identification <br />E -Mail: ocdac .orangecountync.goy <br />Total Project /Program Cost: $30000 Total Amount of Funds Requested: $30000 <br />Proposed Use of Funds Requested (2 -3 Line Maximum): Funding for as- needed basic operating <br />expenses, ADA related workshop employment training, human interest projects, resources, <br />supplies, staff training, computer support, travel and printing. <br />Please check all types, sources, and amounts of funding being requested. You must submit <br />an application package for each funding source. *The Participating Jurisdiction reserves the <br />right to fund projects from any funding source, subject to eligibility and funding constraints. <br />❑ CDBG Non - Construction (CH) $ L1 Grant ❑ Loan <br />LI CDBG Construction (CH) $ ❑ Grant ❑ Loan <br />❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan <br />❑ HOME Other (OC) $ ❑ Grant ❑ Loan <br />Main Application11 /27/2017 8:00:40 PK a,,ge 4 of -4"'S <br />