Express Microchip Grant Application Michelson Found Animals Foundation Please complete this form and tell us how you will use free microchips to support animals in communities impacted by a natural disaster. OK Question Title * 1. What is the name of your organization? OK Question Title * 2. Is your organization a tax exempt organization, under Section 501(c)(3) of the Internal Revenue Code, or a tax exempt government entity? Yes No OK Question Title * 3. If yes, what is your organization's EIN? OK Question Title * 4. Please upload determination letter (if applicable). DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Please upload determination letter (if applicable). OK Question Title * 5. What type of organization are you? (choose one) Pet Rescue Shelter Veterinarian Emergency responder Other (please specify) OK Question Title * 6. What CITY is your organization located? OK Question Title * 7. What STATE is your organization located? OK Question Title * 8. Please name the primary contact for this grant. OK Question Title * 9. What is the email address for your primary contact? OK Question Title * 10. What is your shipping address? OK Question Title * 11. Please list a telephone number for the above contact person. OK Question Title * 12. What is your organization’s annual operating budget? OK Question Title * 13. How many pets do service per year? OK Question Title * 14. From which company do you currently purchase microchips? Datamars Michelson Found Animals 24 PetWatch AVID Home Again Smart Tag Other (please specify) OK Question Title * 15. In multiples of 100, how many microchips are you requesting? How many microchips do you plan to implant in animals in the impacted areas within the next 30 days? OK Question Title * 16. In 150 words or less, please describe how your organization is currently helping the affected victims and how you plan to use our microchips. OK DONE