Spay and Neuter Grant Application
Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).
Facility Information
Facility Name
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Facility Address
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Address 2
City
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State
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Missouri
Alabama
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County
Zip Code
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Primary Phone
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Phone Type
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C-Cell
H-Home
O-Office
Ext.
Alternate Phone 1
Phone Type
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C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 2
Phone Type
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C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
ACFA License Number
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Acfa Num Ext
Contact Person
Prefix
Select
Mr.
Mrs.
Ms.
Last Name
*
Last Name
First Name
*
Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Business Name
Address 1
*
Address 2
City
*
State
*
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
*
Zip Code
-
Ext
County
Select
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
De Kalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Primary Phone
*
Primary Phone
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Phone 1
Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 2
Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 3
Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
E-mail Address
Email
Confirm Email
Confirm E-mail Address
email and confirm email do not match
Confirm E-mail Address
Describe Agency
Validate Organization Selection
Organization Structure
*
City or County Government
Private Nonprofit Agency
Spay/Neuter Clinic
Veterinary Association
Private Veterinary Clinic
Community Collaboration
Validate ServiceSelection"
Service Provided
*
Unlimited Intake Shelter
Limited Intake Shelter
Spay/Neuter Services
Animal Control
Feral Cat Sterilization
Veterinary Care to the Public
Other
Attending Veterinarian
Prefix
Select
Dr.
Mr.
Mrs.
Ms.
Last Name
*
First Name
*
Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Business Name
Address 1
*
Address 2
City
*
State
*
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County
Select
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
De Kalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Zip Code
*
Ext.
-
Primary Phone
*
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Alternate Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
E-mail Address
Confirm E-mail Address
email and confirm email do not match
Validate Discount
Do you have an exisiting program with your attending veterinarian that includes a lower cost or discounted plan?
*
Yes
No
Type of Entity
NonProfit Organization
Government Agency
What county(ies) does your Spay/Neuter Program cover and what is the population of each?
*
Spay NeuterPopulation
Population
County
Select
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
De Kalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Average cost per procedure for the program for which the grant is requested.
*
What criteria does your organization use in determining financial needs of individuals?
*
what criteria does your organization use in determining financial needs of individuals?
What is the target population (E.g. low income, indigent, elderly, shelter animals, etc) intended to served by the program funded by this grant?
*
Describe and quantify, to the extent possible, the pet overpopulation problem in your community using your agency's data and any other meaningful estimates.
*
describe and quantify, to the extent possible, the pet overpopulation problem in your community using your agency's data and any other meaningful estimates.
For your organization, in the last completed year.
*
Dogs
Cats
Admitted
Admitted Dog
-Dogs
Admitted Cat
-Cats
Adopted
Adopted Dog
-Dogs
Adopted Cat
-Cats
Sterilized
Sterilized Dog
-Dogs
Sterilized Cat
-Cats
Euthanized
Euthanized Dog
-Dogs
Euthanized Cat
-Cats
If your program performs adoptions, are all animals sterilized before adoption?
*
Yes
No
Validate sterilized
Does your organization currently have a spay/neuter program?
*
Yes
No
How long has your spay/neuter program been in operation?
Provide the number of procedures performed over the past year by your organization / agency.
*
Spays
Neuters
How many animals were spayed/neutered through your organization/agency during the last year?
*
Dogs
Cats
Has your organization received a grant from the spay/neuter fund in the past?
*
Yes
No
How many procedures were performed with the grant?
Spays
Neuters
Is this funding planned for expanding or enhancing a program?
Yes
No
Does your organization shelter animals?
*
Yes
No
What are your adoption fees?
Describe the general socio-economic need (e.g. poverty levels, unemployment, per capita income, occupational data, etc.) of the counties covered by your spay/neuter program.
*
describe the general socio-economic need (e.g. poverty levels, unemployment, per capita income, occupational data, etc.) of the counties covered by your spay/neuter program.
Describe what community collaborations, if any exist and how this grant will foster the creation or extension of those collaborations.
*
describe what community collaborations, if any exist and how this grant will foster the creation or extension of those collaborations.
What other resources for spay/neuter assistance exist in your community and who are their target populations?
*
what other resources for spay/neuter assistance exist in your community and who are their target populations?
If grants from other organizations are anticipated, please tell us from whom and how much has been requested or awarded.
if grants from other organizations are anticipated, please tell us from whom and how much has been requested or awarded.
Explain how post-surgical monitoring and care will be managed.
*
explain how post-surgical monitoring and care will be managed
How would a grant increase the number of spay/neuter procedures in your community?
*
how would a grant increase the number of Spay/Neuter procedures in your community?
Please describe your plan to promote the "I'm Pet Friendly" license plate.
*
(Attach images to support your plan)
please describe your plan to promote "I'm Pet Friendly" license plate
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Date 12/12/2024
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