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*

Facility Address*

Address 2

City*

State *

County

Zip Code *

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

ACFA License Number

- Acfa Num Ext

Contact Person

Prefix

Last Name*

Last Name	First Name *		Middle Initial		Suffix

Business Name

Address 1*

Address 2

City*		State*		Zip code*	Zip Code - Ext
County

Primary Phone*

Primary Phone	Phone Type	Ext.

Phone 1

Phone 1	Phone Type	Ext.

Phone 2

Phone 2	Phone Type	Ext.

Phone 3

Phone 3	Phone Type	Ext.

E-mail Address

Confirm Email Confirm E-mail Address

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

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Validate Discount

Do you have an exisiting program with your attending veterinarian that includes a lower cost or discounted plan? *

YesNo

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

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

-Dogs

-Cats

Adopted

-Dogs

-Cats

Sterilized

-Dogs

-Cats

Euthanized

-Dogs

-Cats

If your program performs adoptions, are all animals sterilized before adoption? *

YesNo

Validate sterilized

Does your organization currently have a spay/neuter program? *

YesNo

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? *

YesNo

How many procedures were performed with the grant?

Spays

Neuters

Is this funding planned for expanding or enhancing a program?

YesNo

Does your organization shelter animals? *

YesNo

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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Signature

I have read and understand the terms and policies.*

Legal Name*

Date 12/12/2024