Name of organization

Is this a non-profit organization (public or private)? Yes No

How did you find out about CCS?

Has your organization previously contacted CCS? Yes No


If Yes,

When?

Who was the contact at CCS?
Select One Charis Keenum Charles Johnson Kash Krinhop Kim Witt Martha Garcia Opersteny Stacy Rhodes Trey Marchbanks Young Kim Other If other,

Contact person in organization:

Name	First Last
Title
Phone number	( )  -      Ext.
Alt Phone number	( )  -      Ext.
Fax number	( )  -
E-mail address
Organization's website address: http://

Address of your organization:

Address	Mailing address	Street address (if different)
Line1
Line2
City
State
Zip Code	-	-
County	Select Your County Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf Smith Delta Denton DeWitt Dickens Dimmit Donley Duval Eastland Ector Edwards El Paso Ellis Erath Falls Fannin Fayette Fisher Floyd Foard Fort Bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff Davis Jefferson Jim Hogg Jim Wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox Lamar Lamb Lampasas LaSalle Lavaca Lee Leon Liberty Limestone Lipscomb Live Oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick McCulloch McLennan McMullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley N/A Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo Pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red River Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San Augustine San Jacinto San Patricio San Saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom Green Travis Trinity Tyler Upshur Upton Uvalde Val Verde Van Zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala

State Senate District(s)
State Representative District(s)

Don't know?  Click here and type in your zip code.

Proposal and Grants Experience

How would you rate your organization's knowledge of the grant process?
(scale of 1-5, where 1=no knowledge and 5=expert knowledge)

Federal	Select One 1 2 3 4 5
State	Select One 1 2 3 4 5
Local	Select One 1 2 3 4 5
Foundation	Select One 1 2 3 4 5
Overall	Select One 1 2 3 4 5

Has your organization previously applied for a competitive grant?

Yes No

If yes, then what type of grants (check all that apply):

Federal  State  Local  Foundation

Types of Assistance

For a description of the types of assistance available, click here.

What type of assistance are you seeking? (check all that apply):

Information & Data Services	Funding Searches
Proposal Writing Services	Review & Comments

Organization Information

When was your organization founded?(year)

Is there an active Board of Directors in your organization? Yes No

What is your organization's total budget this year?

$ .00

How many employees are there in your organization?

Full-Time?
Part-Time?
Volunteer?

Please give a general description of your organization's Mission and Services provided

What is your organization's service delivery area? Select One Neighborhood City County Multi-County School District Region State

Please select up to 2 types of support needed:

1st Type of Support Needed	Select One Building Funds Continuing Support Emergency Funds Equipment General Purposes In-Kind Gifts Matching Funds Operating Budgets Renovation Project Research Scholarship Funds Seed Money Special Projects Technical Assistance
2nd Type of Support Needed	Select One Building Funds Continuing Support Emergency Funds Equipment General Purposes In-Kind Gifts Matching Funds Operating Budgets Renovation Project Research Scholarship Funds Seed Money Special Projects Technical Assistance

Please select up to 3 of your organization's proposal areas of interest:

1st Area of Interest	Select One Animal Related Activities Arts/Culture & Humanities Civil Rights/Advocacy Community Improvement Education Employment Environment Food/Nutrition/Agriculture Health Housing/Shelter Human Service International/Foreign Affairs Medical Research Mental Health Philanthropy & Voluntarism Public Affairs/Government Public Protection Public Safety Recreation Religion Science & Technology Social Science Youth Development
2nd Area of Interest	Select One Animal Related Activities Arts/Culture & Humanities Civil Rights/Advocacy Community Improvement Education Employment Environment Food/Nutrition/Agriculture Health Housing/Shelter Human Service International/Foreign Affairs Medical Research Mental Health Philanthropy & Voluntarism Public Affairs/Government Public Protection Public Safety Recreation Religion Science & Technology Social Science Youth Development
3rd Area of Interest	Select One Animal Related Activities Arts/Culture & Humanities Civil Rights/Advocacy Community Improvement Education Employment Environment Food/Nutrition/Agriculture Health Housing/Shelter Human Service International/Foreign Affairs Medical Research Mental Health Philanthropy & Voluntarism Public Affairs/Government Public Protection Public Safety Recreation Religion Science & Technology Social Science Youth Development

What sources for funding is your organization currently targeting?

Select One Federal State Private Foundation Corporate Foundation Mixed Others None

If currently targeting funding, then please list the name of the grant and funding source?

Legal Classification of Organization

How is your organization legally classified?

I. Government II. Quasi-Government III. Private Non-profit

Please Specify Select One State County Municipal Independent School District State Institution of Higher Learning Private University Native American Tribe Other Government If other, describe

Please Specify Select One Intermunicipal Interstate Special District Other Quasi-Government If other, describe

Please Specify Select One 501(c)(3) 501(c)(4) Other Private Non-profit If other, describe

Service Classification of Organization

Please review these service classification descriptions before choosing one that best fits your organization.

Please select a service classification for your CBO:

Select One Not Specified Community Service and Action Health Educational Personal-Growth, Self-Development, Self-Improvement Social Welfare Self-Help Disadvantaged and Minority Public Safety Other

If other, please describe:

 

Target Populations Served by Organization

Primary target population of your organization:

Select One Abused Children/Adults Adults At-Risk Youth At-Risk Adults African Americans Bilingual Delinquents Drop-outs Elderly Ethnic Minorities Fathers Females Gangs Handicapped/Disabled Hispanics HIV Homeless Illiterates Incarcerated Populations Infants Low-Income Males Malnourished Migrants Medically Underserved Mothers Parents Police Pregnant Teens Public Housing Residents Seniors Single Parents Special Needs Children Students Substance Abusers Teachers Teens/Youth Unemployed Urban Other   If other,

Secondary target population of your organization:

Select One Abused Children/Adults Adults At-Risk Youth At-Risk Adults African Americans Bilingual Delinquents Drop-outs Elderly Ethnic Minorities Fathers Females Gangs Handicapped/Disabled Hispanics HIV Homeless Illiterates Incarcerated Populations Infants Low-Income Males Malnourished Migrants Medically Underserved Mothers Parents Police Pregnant Teens Public Housing Residents Seniors Single Parents Special Needs Children Students Substance Abusers Teachers Teens/Youth Unemployed Urban Other   If other,

Would you like CCS staff to contact you upon receipt of your CBO registration form? Yes No