Organization Information:

Organization Name: *

Organization Address: *

Contact Person Name: *

Contact Person Title: *

Office Phone: *

Cell Phone: *

Fax: *

Email Address: *

Eligibility Information:

Q1. Does your organization currently have an AED? If “yes” you are not eligible for this program. *

Yes No

Q2. Describe your organization and how you serve your constituency. *

Q3. Describe the constituency whom you serve. What is the typical income level of those you serve?
What age groups do you serve? *

Q4. In a typical month, how many people come to your location? If you are a house of worship,
what is the size of your congregation? *

Q5. Describe the types of health related programs your organization has undertaken, if any.
(e.g., health screening, nutrition or other programs.) *

Note: Fields marked with * are required.