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Cover Page P a g e 8 o f 55 <br />COVER PAGE <br />Applicant Contact Information <br />Applicant Organization’s Legal Name: Club Nova Community, Inc. <br />Applicant Organization’s Physical Address: 103 D West Main Street, Carrboro, NC <br />27510 <br />Applicant Organization’s Mailing Address: PO Box 1346, Carrboro, NC 27510 <br />Applicant Organization’s Web Address: clubnova.org <br />Executive Director: Karen Kincaid Dunn <br />Telephone Number: 919-968-6682 E-Mail: karendunn@nc.r.com ; <br />kdunn@clubnova.org <br />Tax ID Number: <br />Funding Request <br />Please list all Fiscal Year 2022 Human Services (HS) funding requested for all <br />programs and the proposed use of funds (please list program name only) <br />Program Carrboro - HS Chapel Hill - HS Orange County-HS Total <br />Critical Safety Net – <br />Livelihood Security <br />& Improved Health <br />Outcomes <br />$22,000 Personnel <br />& Operations <br />$22,000 Personnel <br />& Operations <br />$15,000 Personnel & <br />Operations <br />$59,000 <br />Transportation $65,000 Personnel & <br />Operations <br />$65.000 <br />Employment $22,000 Personnel & <br />Operations <br />$22,000 <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614