Application for Funding Form
SECTION #1 - GENERAL INFORMATION
Organization Name:
Street Address:
Apt./Suite:
City:
County:
State:
Zip Code:
Telephone (office):
Telephone (home):
Contact Nameand Title:
Contact E-mail:
How did you hear about our Foundation:
EIN Number:
(You must attach a copy of your organization’s 501(c)(3) Approval Letterfrom IRS. We cannot consider your application without a copy of this document.)
Web Site:
SECTION #2 – FINANCIAL INFORMATION
Balance Sheet
Assets:
Liabilities:
Current Net Worth:
(Please attach any additional explanation to this form.)
Annual Revenue
Revenue:
Expenses:
Net Profit:
(Please attach any additional explanation to this form, along with last year’s tax return preferred.)
Describe your organization’s physical facility (own or rent)?
Does your organization currently receive financial assistance from Federal, State or local government sources (if yes, please explain):
Has your organization ever received a grant from the Dr. Jane’s HealthyPetNet Foundation (if yes, please state when):
How do you generate money for your organization?
SECTION #3 – OPERATION INFORMATION
What species of animals does your organization rescue:
Please state your organization’s mission:
Please state your organization’s short-term and long-term goals:
How long has your organization been in operation:
Who runs the daily operations of your organization and are they salaried or volunteers:
How has your organization grown over the last few years (for example, have you increased adoptions, increased space, worked with other animal organizations, etc.):
If you have a facility, describe your premises in detail (for example, the total number of animals you house, animals per unit, number of cages, number of runs, etc.)
If appropriate, describe your cleaning protocol in detail:
Describe your medical protocol in detail (please include your veterinarian’s name and phone number):
SECTION #4 – FOSTERING/ADOPTION INFORMATION
Foster Home Program (Does your organization have a foster program and if so please attach applicable contract to this form):
Approximately how many animals where fostered last year and how many do you anticipate on fostering this year:
What is the average amount of time an animal is fostered:
Adoption Program (Does your organization have an adoption program and if so please attach applicable contract to this form):
What is the average length of time an animal stays with youor is fostered before the animal is adopted:
Are the animals neutered prior to adoption:
What is your protocol for socializing animals with behavior problems:
What information do you give new adoptive pet parents:
What is your adoption fee:
If the adoptive pet parents are not able to care for the new pet, what is your policy:
Approximately how many animals where adopted last year and how many do you anticipate on adopting this year:
SECTION #5 – EUTHANASIA INFORMATION
Describe your policy in terms of euthanasia, as it relates to the following.
Terminal Disease:
Behavior problems:
When the cost of care is too much:
Who determines the fate of animals:
SECTION #6 - FUNDING REQUEST INFORMATION
Please specifically describe the amount of funds you are seeking for the promotion, establishment, maintenance or management of your organization. Also, identify your organization’s specific purpose for the funds your organization is seeking. (Awards average from between $1,000-$2,000, but could be as much as $3,000 if warranted by special circumstance.)
Date Submitted:
This form was created in Microsoft Word. You can open it and type in the answers. Once completed, save the document and email it along with the appropriate attachments to . If you prefer, you may fax the completed document along with appropriate attachments to (561) 745-2373.
If you wish to contact us, please callDr. Jane Bicks Monday-Friday from 9AM to 5PM Eastern Time at 863-763-4239.
Dr. Jane’s HealthyPetNet Foundation, Inc. EIN: 20-5373896
101 Capital Street, Jupiter, Florida 33458
Email:
06-24-13