Application for Assistance

Email *

Today's Date

Your Spouse's Employer (Name and Address) *

Your Spouse's Length of Employment

List any Government Assistance *

Check box *

By checking this box, I certify that the above information is true. I understand any pet care assistance I may receive will be provided to my pets based on the information above. I understand in order to receive pet care assistance I must be a resident of Moffat County.

If request is for medical assistance, how much can you afford to contribute at this time?

Type of assistance requested and reason (please explain) *

If the veterinarian is willing to offer a payment plan, will you take advantage of this option?

Yes

If no, why?

Number of dependents (including self/spouse) *

Home Mailing Address *

Your Name: *

Home Phone *

Work Phone

Spouse's Name (if applicable)

Home Physical Address *

Cell Phone

Total household income *

Your Employer (Name and Address) *

Your Length of Employment *