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19 <br /> ORANGE COUNTY ORANGE COUNTY <br /> NORTH CAROLINA HIGH IMPACT OPIOID ABATEMENT <br /> STRATEGIES <br /> Funding Proposal Application Form <br /> Application Due Date: February 21, 2025 <br /> Applicant Agency: General Information <br /> Legal Name Click or tap here to enter text. <br /> Address Click or tap here to enter text. <br /> Type of Agency ❑ Government/ <br /> (check one) Public Authority ❑ Non-Profit ❑ For-Profit Business <br /> Telephone Click or tap here to enter text. <br /> Website Click or tap here to enter text. <br /> Primary Contact Full Name Click or tap here to enter text. <br /> Title Click or tap here to enter text. <br /> Email Click or tap here to enter text. <br /> Telephone Click or tap here to enter text. <br /> Name of Project Click or tap here to enter text. <br /> Total Application Funding Requested $ Click or tap here to enter text. <br /> Funding Period Requested Start Click or tap here End Click or tap here to <br /> (MM/DD/YYYY) Date to enter text. Date enter text. <br /> Selected NC MOA Option A Strategy(Number <br /> and Name) Click or tap here to enter text. <br /> Agency Mission and Vision Statements Click or tap here to enter text. <br /> Use font size 12 throughout document. <br /> As a separate Excel file, submit a completed Budget Worksheet. <br /> Submit application to tstancil@oranBecountync.gov with a subject line of— RFA: Opioid <br /> Settlement Funds— [Organization name]. Will receive Receipt of Application email upon <br /> submission. If email is not received within 24 business hours, reach out to Tonya Stancil, Harm <br /> Reduction Coordinator at tstancil@orangecountync.gov. <br /> i <br />