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<br />FY 2020-21 Outside Agency <br />Contact Information <br />1 <br /> <br /> <br />Congratulations on being awarded Outside Agency Funding for FY 2020-21! <br />Please provide the below information regarding your agencies’ contacts for fiscal year 21. <br />Please complete and sign this form electronically and submit to Allen Coleman at <br />outsideagencies@orangecountync.gov by Friday, August 14, 2020. <br />Section A: Agency Information: Agency Legal Name Agency DBA (If Applicable) Physical Address Mailing Address Agency’s Telephone Number Agency Website <br /> <br />Section B: Executive Director’s Information Executive Director’s Name Executive Director’s Telephone Number Executive Director’s Email Address Will the Executive Director Sign the Performance Agreement? YES NO <br />If no, please tell us who? – Name: Email Address What type of Communications should this individual receive? <br />Please select check all that apply: <br />___ Application Orientation & <br /> Training Opportunities <br />___ Financial Reporting <br />___ Performance Reporting <br /> ___ Performance Agreement Execution <br /> <br />Senior Care of Orange County, Inc <br />105 Meadowlands Drive, Hillsborough, NC 27278 <br />105 Meadowlands Drive, Hillsborough, NC 27278 <br />919-245-2017 <br />Dawniell Boykin <br />919-245-2017 <br />dboykin@orangecountync.gov <br />4 <br />4 <br />4 <br />4 <br />4 <br />DocuSign Envelope ID: 4A1A8EC9-D4E0-4A05-A302-572F4C69566D