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Attachment A <br /> <br /> C~arrz:~ Counfy P~rk~ ~nd Re,re,rio# ~ep~rfme~! <br /> P.O. ~ox 707~ Conoord, NC 28026-0707 <br />TCHINg INCENTIVE g ANT APPLI ANT INFORHA TION FOR <br /> Fisea! YeAr ~004 - <br /> <br />1. APPLICANT INFORMATION <br />ORGANIZATION NAME NON-PROFIT <br /> YES NO <br />ADDRESS PHONE NUMBER FAX NUMBER OTHER NUMBER <br />=ROJECT COORDINATOR'S NAME <br />EMAIL ADDRESS <br />~.DDRESS PHONE NUMBER FAX NUMBER OTHER NUMBER <br /> <br />SCHOOL PRINCIPAL'S NAME (IF PROJECT LOCATED ON SCHOOL PROPERTY) <br />EMAIL ADDRESS <br /> <br />ADDRESS PHONE NUMBER FAX NUMBER OTHER NUMBER <br />2. PROJECT INFORMATION <br />DESCRIPTIVE TITLE OF PROJECT <br />3ROJECT SITE <br />STREET ADDRESS CITY STATE ZIPCODE <br />AREAS AFFECTED BY PROJECT: NEW PROJECT START DATE <br />(SCHOOLS, MUNICIPALITIES, ETC,) <br /> ON-GOING PROJECT COMPLETION DATE <br /> <br /> WILL A FEE BE CHARGED FOR USE ON-GOING MAINTENANCE FOR PROJECT WILL BE PROVIDED BY' <br /> OF FACILITY/PROJECT? <br /> _ YES ~ NO <br /> ESTIMATED FUNDING. TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL DATA IN THIS APPLICATION IS TRUE AND CORRECT THE <br /> DOCUMENT HAS BEEN AUTHORIZED BY THE GOVERNING BODY OF THE APPLICANT AND THE APPLICANT WILL <br /> APPLICANT $ COMPLY WITH THE ATTACHED ASSURANCES IF THE GRANT IS AWARDED, <br /> TYPED NAME OF PROJECT COORDINATOR <br /> COUNTY $ <br /> IN-KIND $ <br /> SIGNATURE OF PROJECT COORDINATOR <br /> TOTAL <br /> <br /> <br />