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DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF <br /> EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION <br /> FY2018-19 <br /> MENTAL HEALTH SERVICES APPLICATION <br /> a) Applicant Contact Information <br /> Applicant Organization's Legal Name: Institute of Art Therapy, Inc. (DBA: Art Therapy Institute) <br /> Applicant Organization's Physical Address: 200 N. Greensboro St., D-6 Carrboro, NC 27510 <br /> Applicant Organization's Mailing Address: 200 N. Greensboro St., D-6 Carrboro, INC 27510 <br /> Applicant Organization's Web Address: ncati.org <br /> Executive Director: Hillary Rubesin <br /> Telephone Number: 919-381-6068 E-Mail: hrubesin(a_)ncati.org <br /> Tax ID Number: 26-3447555 <br /> b) Funding Re uest <br /> Program Total <br /> Ex. Youth Afterschool Program $30,000 <br /> Afterschool Program Coordinator salary and materials <br /> for youth activities and projects <br /> Newcomers Art Therapy Program: Payment for $27,600 <br /> therapy services, cultural/clinical training and <br /> supervision, research and evaluation, and interpreter <br /> services. <br /> Totals $27,600 <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: 8/29/2018 <br /> Executive&Jrector Date <br /> Signature. SVA� M <br /> T 08/29/2018 <br /> Board Chairperson Date <br /> AGENCY INFORMATION 8/28/2018 5.02.49 PM <br />