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DocuSign Envelope ID: EE049453-18E5-41 DO-666D-662773AMC09 <br /> EXHIBITA: Provider's Outside Agency Application <br /> 1. COVER PAGE <br /> ig Apalicant Contact Information <br /> Applicant Organization's Legal Name: Triangle Bikewarks <br /> Applicant Organization's Physical Address: 117WestMain I. Suite C1 Carrboro NC 2 510 <br /> Applicant Organization's Mailing Address: 117 West Main Street Carrboro NC 27510 <br /> Applicant Organization's Web Address: Trian iebikework .or <br /> Executive Director: Kevin Hicks <br /> Telephone Number: 919-408-7513 E-Mail: kevinCa7trianglebikewyrks.org <br /> Tax ID Number: 46-1229632 <br /> b) Funding Request <br /> List all FY18-19 Human Services (HS) Funding Being Requested— <br /> For All Programs) and t a Proposed Use of Funds (2-3 lines or less) <br /> Program _Y f Carrboro Chapel Orange Total <br /> -H$ ilk l HS Coun -HS <br /> Ex.Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Spoken Revolutions Cycling Program $7,500 $7,500 $7,500 $22,500 <br /> Totals <br /> c) To the best of my knowledge and belief all information and data in this application is true <br /> and current. The document has been duly authorized by the governing board of the <br /> applicant. <br /> Signature: � 6 <br /> . <br /> � �-YS 6 <br /> E ecuti Director pate <br /> Signature: <br /> eBoalChairperson Date b <br />