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AGENCY INFORMATION 8/31/2018 11:35:08 AM Page 1 of 11 <br />FY2018-19 <br />MENTAL HEALTH SERVICES APPLICATION <br />a)Applicant Contact Information <br />Applicant Organization’s Legal Name: New Destinations, Inc. <br />Applicant Organization’s Physical Address: 5720 Turner Store Lane –Raleigh, NC 27603 <br />Applicant Organization’s Mailing Address: 5720 Turner Store Lane –Raleigh, NC 27603 <br />Applicant Organization’s Web Address: www.newdestinationsinc.com <br />Executive Director: Larry Lackey <br />Telephone Number:(919) 414-2860E-Mail: larrylackey@newdestinationsinc.com <br />Tax IDNumber: 26-4220482 <br />b)Funding Request <br />Program Total <br />Ex. Youth AfterschoolProgram <br />Afterschool Program Coordinator salary and materials <br />for youth activities and projects <br />$30,000 <br />Orange Apartments-Residential Services for Adults <br />with Severe Persistent Mental Illness $35,100 <br />Totals $35,100 <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: <br />Executive DirectorDate <br />Signature: <br />Board ChairpersonDate <br /> <br /> <br />Exhibit A <br />Provider's Cardinal Managed Care Application and Work Statement <br />DocuSign Envelope ID: 45F8D9E2-21AC-4868-9A00-7CEFD1517F11