Please complete this form and return it to: Penny Reeves, CAQHA, 175 Darden Hill Rd., Driftwood, TX 78619, or email a scan of the completed form to: penny.graymar@gmail.com Please type or print clearly. Name of organization: Non-profit status: Contact individual for organization: Email: Title: Phone: Address: Organization website (if applicable): 1. Tell us what kind of work your organization does: 2. Number of animals assisted in previous calendar year (if applicable): Please describe type of assistance provided: Do you expect to provide same level of assistance over the next 12 months? 3. Number of humans assisted in previous calendar year (if applicable): Please describe type of assistance provided: Do you expect to provide same level of assistance over the next 12 months? 4. Assistance/Community Outreach or Support - Other Than Above (please describe): 5. Wish List for your organization- Please list the things you need the most, and why, and estimated costs or value associated: 6. Please include any other information that you think would be helpful for us to know about your organization:

Grant Application Form