| Your Name |
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| Your Title |
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| Your Organization |
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| Your Address |
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| City |
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| State |
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| Zip Code |
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| Your Email Address |
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| Your Phone Number |
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| Your Fax |
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| Organization Mission |
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| NonProfit Status |
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| EIN Number |
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| Board and Staff members are free of convictions |
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| No Board or Staff members have a financial interst in organization (ADAH) |
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| Organization has one separate financial or accounting person or function |
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| Organization has a conflict of interest policy and procedures |
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| The organization has at least 3 board members |
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| Resources needed from ADAH |
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| The organization is actively engaged in feeding homeless |
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