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Exhibit A -1— Standardized Proposal Information <br />DEPARTMENT OF RESEARCH AND DEVELOPMENT <br />COUNCIL CONTINGENCY FUNDS <br />Proposal Reference Number: <br />(For Department Use) <br />Name of Organization: West Hawai'i Community Health Center, Inc. <br />Project Title: WHCHC at Kealakehe, Equipment, Supplies & Furnishings <br />Mailing Address: 75 -5751 Kuakini Highway, Suite 203, Kailua -Kona, Hawaii 96740 <br />Physical Address: 75 -5751 Kuakini Highway, Suite 203, Kailua -Kona, Hawaii 96740 <br />Telephone: 331 -6472 Fax: 327 -1939 <br />Organization E -Mail Address: lavery @westhawaiichc.org <br />Federal Tax ID #: 200495394 General Excise Tax #: <br />Lauren Avery, Director of Development <br />Contact Name: and Marketing Title: <br />Telephone: 331 -6472 <br />Contact E -Mail Address: <br />Amount Requested: <br />Program Area <br />(Please select just one). <br />If different from above <br />lavery @westhawaiichc.org <br />$ 15,000.00 <br />❑ Agriculture <br />® Community Building <br />❑ Film <br />Fax: <br />If different from above <br />❑ <br />Business Development <br />❑ <br />Energy <br />❑ <br />Tourism <br />Project Summary: (brief description of the project including goals, objectives & <br />outcomes ): <br />The West Hawai'i Community Health Center, Inc., a 501(c)(3) nonprofit <br />organization, that is completing construction of their newest facility at <br />Kealakehe, named: West Hawai'i Community Health Center - Kealakehe. The <br />request for funds is to purchase equipment, supplies and furnishings for its <br />newest facilitv at Kealakehe. <br />RD ED Contingency Funds Forms Word <br />