Orange County NC Website
Browse       Search
DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: The Arc of the Triangle, Inc. <br /> Applicant Organization's Physical Address: 1709 Legion Road Suite 100 CH NC 27517 <br /> Applicant Organization's Mailing Address: same <br /> Applicant Organization's Web Address: www.arctriangle.org <br /> Executive Director: Jennifer Pfaltzgraff <br /> Telephone Number: 919 942 5119 xt 117 E-Mail: ipfaltzgraffsa�__arctriangle.org <br /> Tax ID Number: 56-1214133 <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 Carrboro FHi�l el Orange Total <br /> - HS HS Count -HS <br /> Ex. Youth Afterschool Program $10,000 00 $5:000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Social and Volunteer Programs, Individual Services, $7,500.00 $12,000.00 $7500.00 $27,000.00 <br /> Petals with a Purpose, Health and Wellness Cooking <br /> Class, HOOPs Basketball, Spin Class, Friday Fun <br /> Day, HOPE Gardens, Summer Work and Wellness <br /> Program. Funding used to cover supplies, materials, <br /> brochures, publicity, salary. <br /> Totals $7500.00 $12,000.00 $7500.00 $27,000.00 <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: t <br /> E4 c ]ve Director Date <br /> Signature: LLB/ <br /> Board Chair rson Date <br /> AGENCY INFORMAT N 1/26/2017 5:52;39 PM Page 6 of 26 <br />