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.FORM 01 <br />DEPARTMENT OF HEALTH AND HUMAN SERVICES <br />FIUMAN SERVICES-GRANTS <br />TITLE AND AUTHQRI?.ATION PAGE. <br />Program Name:. Men's Resideirtial House and LifeSkills ~ducaxion~gr~m <br />Qrganization Name: ~Fre~~n I-~ouse Re~verv Cgnler <br />Organization Tax ID Number: 560826'74 <br />Address: 104 Ne~,sidg Drive <br />Chavel Hill. North Camlin,~ 27516 <br />List County or Counties 'fo Be Served by the Giant. If Statewide, Sirriplq Write Statewide: <br />O e t Y e 11 <br />Program Director: Trish I-sey, <br />Title: Executive Iirector Phone Number (91.9) 942-2803 <br />Address: Same as Above <br />Contact Person: Trish Hussey Phone Number (919 9Z,, 42-203 <br />Total Funds Requested: $100,000 <br />Has this agency/entity applied for funding for this project from another source? Indicate: <br />Yes X or No If yes, iderrtify the source: Kate B. Revnol~,s HCT, Coun of Orange. and <br />OPC Mental Hgg~ Progr~tn. <br />AUTHORIZATI~IN: <br />We/I, the undeasigned, have read and understand the requirenu~tts a>ntained in the grant and' hereby make <br />'on far the finds. All 'tares shall be in co fiance with grant requirements. <br />Signature omas It lrciana7n, M.D. Date <br />Chairtriat~/President of flue Board:- (Identify Correct Title <br />lay Unde~rlinMing & Type in the Name beside th,e Word Signature <br />~!6~ <br />Signature Aim Frey Date <br />Treasurer/Financial Officxr of the Board -(Identify concert <br />Title 63' Underlining 8c Type inthe Name beside the Word Signature. <br />Approved by: Secretary H. David Bruton, M.D. Date <br />Departmern of Health and Human Services <br />3 <br />Vol. II 1999-2000 <br />