Exit MoCAP Potential Customer Worksheet Thank you for your interest in Missouri Foundation for Health’s MoCAP program! MoCAP offers technical support and consulting services free of charge to eligible organizations pursuing nationally competed federal or private funding for health- or prevention-focused programs. MoCAP resources are available to nonprofits and governmental organizations that serve people or communities within our service region. An organization’s current or prior status as an MFH grantee has no bearing on using MoCAP services. Please complete this worksheet as thoroughly as possible, enlisting the help of other staff within your organization when necessary. MoCAP staff will use the information provided to become familiarized with your organization’s experience with; and interest in; competitive federal and national funding opportunities. Once we receive your completed worksheet, a MoCAP staff member will follow up to go over next steps.*NOTE* Standard lead time for MoCAP support is 5-8 weeks from receipt of request to application deadline. MFH may not be able to provide support on grant applications due less than 5 weeks from today. For more information visit MoCAP FAQ Question Title * PRIMARY CONTACT INFORMATION Name: Title: Email Address: Phone Number: Question Title * ORGANIZATION INFORMATION Name (no acronyms): Street Address: Suite/Floor: City: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Zip: Question Title * COUNTY/COUNTIES SERVED (select all that apply): Adair Audrain Barry Barton Bollinger Boone Butler Callaway Camden Cape Girardeau Carter Cedar Chariton Christian Clark Cole Cooper Crawford Dade Dallas Dent Douglas Dunklin Franklin Gasconade Greene Hickory Howard Howell Iron Jasper Jefferson Knox Laclede Lawrence Lewis Lincoln Linn Macon Madison Maries Marion McDonald Miller Mississippi Moniteau Monroe Montgomery Morgan New Madrid Newton Oregon Osage Ozark Pemiscot Perry Phelps Pike Polk Pulaski Putnam Ralls Randolph Reynolds Ripley St. Charles St. Francois St. Louis Ste. Genevieve Schuyler Scotland Scott Shannon Shelby Stoddard Stone Sullivan Taney Texas Warren Washington Wayne Webster Wright Question Title * YEAR OF INCORPORATION: Question Title * ANNUAL OPERATING BUDGET: Question Title * RELATIONSHIP TO MFH: Current grantee Former grantee Current MoCAP customer Former MoCAP customer Previous interaction, no funding or MoCAP assistance No previous interaction Unknown Question Title * MISSION STATEMENT: Question Title * SERVICES PROVIDED: Question Title * FOCUS AREA(S): Access to Food Aging/Older Adults Agriculture Behavioral Health Broadband Children/Youth Community Development Criminal Justice Disability Economic Development Economic Stability Education Emergency Response Entrepreneurship Environmental Health Firearm Suicide Prevention Firearm Violence Prevention Government Grassroots Organizing Healthcare Health Equity Health Policy Housing Human Trafficking Immigrant & Refugee Health Infant Mortality Interpersonal Violence Prevention Legal Maternal Mortality Mental Health Oral Health Public Health Racial Equity Reproductive Health Rural Health Social Enterprise Substance Use Disorder Suicide Prevention Technology Tobacco Control Transportation Trauma Violence Prevention Women's Health Workforce Development Other (please specify) Question Title * Is your organization interested in applying for a specific funding opportunity? Yes No Next
