Orange County NC Website
Browse       Search
DocuSign Envelope ID:C70973D3-D989-4F31-A95E-3BCC099C95E7 XHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> 1. COVER PAGE <br /> a) Applicant Contact,Information. <br /> Applicant Organization's Legal Name: Institute of Art Therapy,-fnc. <br /> Applicant Organization's Physical Address; 2a O N. Gre nsbor_o_St._Stea-D-6,__CarrbnroNC <br /> Applicant Organization's Mailing Address: Same <br /> Applicant Organization's Web Address: www.ncatiarg <br /> Executive Director: Kristin Linton <br /> Telephone Number: 919_381-6(}68 E-Mail: klinton mcati,org- <br /> Tax ID Number: 26-3447555 <br /> b) Funding Request <br /> List all FYI 7-18 9 urnan Services Funding Being Requested — <br /> For.All„Prpgrra;ro ) and the Proposed Use of Funds (2-3 lines or less) <br /> fragcam CaWboro. Chapel [}rag e Total <br /> -HS Hill-BS Count -HS <br /> Ex. Youth Afterschooi Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> The Newcomers Art Therapy Program `y $5000 $5000 $5000 _ $15000 <br /> Totals - <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: -- - -- f I- <br /> Executive Director Date <br /> Signature: <br /> Board Chairperson Date <br /> AGENCY INFORMAT10N 115/2017 12:59:10 PM <br />