Kings County Animal Services Pet Pantry Application

1
I agree to/Estoy de acuerdo con:* This field is required.* Provide verification that all pets are microchipped/Proporcionar verificación de que todas las mascotas tienen microchip * Provide my own transportation to pick up food/Proporcionar mi propio transporte para recoger la comida. * Provide written verification of financial need to the Pet Pantry as requested/Proporcione una verificación por escrito de la necesidad financiera a Pet Pantry según lo solicitado * Provide proof of residence/Proporcionar prueba de residencia * Maintain healthy living conditions for my pets/Mantener condiciones de vida saludables para mis mascotas. * Return food buckets or bags CLEAN and DRY/Devuelva los baldes o bolsas de alimentos LIMPIOS y SECOS
I agree/Estoy de acuerdoI don’t agree/no estoy de acuerdo
2
I agree that I will NOT/Acepto que NO lo haré* This field is required.* Use my pet(s) for breeding or any illegal activity/Usar mi(s) mascota(s) para crianza o cualquier actividad ilegal * Add additional pets to our household through adoption, purchase, or any other means, including temporary care and housing/Agregar mascotas adicionales a nuestro hogar a través de la adopción, la compra o cualquier otro medio, incluido el cuidado y la vivienda temporales. * Use Pet Pantry food to feed stray, foster, feral, or outdoor cats/Use la comida Pet Pantry para alimentar a gatos callejeros, adoptivos, salvajes o al aire libre * Re-sell or donate Pet Pantry food or other items to any other person(s) or organization(s)/Vender o donar alimentos u otros artículos de Pet Pantry a cualquier otra persona u organización
I agree/Estoy de acuerdoI don't agree/no estoy de acuerdo
3
I agree that I will inform Pet Pantry of/Acepto que informaré a Pet Pantry de* This field is required.* Any change in my financial situation/Cualquier cambio en mi situación financiera * Any change in my contact information, such as an address, phone number, or email/Cualquier cambio en mi información de contacto, como una dirección, número de teléfono o correo electrónico * The death of my pet/La muerte de mi mascota.
I agree/Estoy de acuerdoI don't agree/no estoy de acuerdo
4
I understand that pet supplies are donated, and the Pet Pantry cannot guarantee the availability of any special foods.* This field is required.Entiendo que se donan suministros para mascotas y que Pet Pantry no puede garantizar la disponibilidad de ningún alimento especial.
YES/SINO/NO
5
I allow Pet Pantry to use photos of me, my family, or my pets taken at food distribution. I relinquish all rights to monetary gain and compensation from the use of such photos.* This field is required.Permito que Pet Pantry use fotos mías, de mi familia o de mis mascotas tomadas en la distribución de alimentos. Renuncio a todos los derechos de ganancia monetaria y compensación por el uso de tales fotos.
YES/SINO/NO
6
I understand and agree that Kings County Animal Services' Pet Pantry makes no warranties as to the pet food and supplies, and does not assume any liability and/or guarantee for these pet food supplies in any way. I take full responsibility for any risks involved in introducing a different food for my pet.* This field is required.Entiendo y acepto que la despensa de mascotas de Kings County Animal Services no ofrece garantías en cuanto a los alimentos y suministros para mascotas, y no asume ninguna responsabilidad ni garantía por estos suministros de alimentos para mascotas de ninguna manera. Asumo toda la responsabilidad por los riesgos que implica la introducción de un alimento diferente para mi mascota.
YES/SINO/NO
7
By signing this application, I and the members of my household and family agree to indemnify Kings County Animal Services' Pet Pantry, their officers, director, member agents, employees, and volunteers, and hold harmless from and against any direct, indirect, special, incidental, punitive, or consequential damages, including but not limited to injury to or loss of my pet, which may arise from my decision to accept and use the pet food.* This field is required.Al firmar esta solicitud, los miembros de mi hogar y mi familia y yo acordamos indemnizar a la despensa de mascotas de Kings County Animal Services, sus funcionarios, director, agentes miembros, empleados y voluntarios, y eximir de toda responsabilidad a cualquier persona directa, indirecta o especial. , daños incidentales, punitivos o consecuentes, incluidos, entre otros, lesiones o pérdida de mi mascota, que pueden surgir de mi decisión de aceptar y usar el alimento para mascotas.
YES/SINO/NO
8
I am aware of the following DISQUALIFICATIONS/Soy consciente de las siguientes DESCALIFICACIONES:* This field is required.* If I add additional pets to my household, I will be immediately disqualified, and will no longer be eligible to receive handouts/Si agrego mascotas adicionales a mi hogar, seré descalificado de inmediato y ya no seré elegible para recibir folletos. * If I fail to produce witten verification of need and microchip information, I will be removed from the program/Si no presento una verificación por escrito de la necesidad y la información del microchip, seré eliminado del programa. * If I return buckets or bags that have not been properly scrubbed and dried, I may be sent home to clean them/Si devuelvo cubos o bolsas que no se han fregado y secado correctamente, es posible que me envíen a casa para limpiarlos.
YES/SINO/NO
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Name/Nombre* This field is required.Last name/apellido, First name
Last name, First name
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Phone Number/ Número de teléfono* This field is required.
11
Secondary phone number/ Número de teléfono secundario
12
Address* This field is required.
Address/ Dirección
Street Address Line 2
City/Ciudad
State / Province
Postal / Zip Code
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Other
Country
13
PO Box
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Email Address/Dirección de correo electrónico
example@example.com
15
How many pets are in your household?¿Cuántas mascotas hay en su hogar?
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Have any of your pets been used for breeding?¿Alguna de sus mascotas ha sido utilizada para la cría?
Yes, currently/Si, actualmente
Yes, in the past/Si, en el pasado
No/No
Other/Otro
17
How often do you plan to use our services?* This field is required.¿Con qué frecuencia planea utilizar nuestros servicios?
One time/Una vez
Month/Al mensual
Twice a month/Dos Veces al mes
18
Check all that apply:Marque todo lo que corresponda:
Disabled/Discapacitado
Unemployed/Desempleado
Veteran/Veterano
Senior/Mayor
None/Ninguno
19
How else can we assist you in the care of your pet?¿De qué otra manera podemos ayudarlo en el cuidado de su mascota?
Huge
Large
Normal
Small
Ok
Ok
20
Check which you will provide as proof of financial need:
SSI or Disability benefits letter/SSI o carta de beneficios por discapacidad
Unemployment benefits letter/Carta de beneficios por desempleo
Bankruptcy letter/Carta de bancarrota
Supporting documents for low income/Documentos de respaldo para bajos ingresos
21
Upload proof of financial needSubir prueba de necesidad financiera
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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22
Pet Information* This field is required.Información de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
23
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
24
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
25
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
26
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
27
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
28
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
29
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
30
Pet InformationInformación de mascotas
Pet's Name/ Nombre de mascota
Please Select
Please Select
Dog/Perro
Cat/Gato
Species/Especie
Please Select
Please Select
Yes/Si
No/No
Spay/Neuter/Castrado
Breed/Raza
Age (include months or years)/Edad (incluir meses o anos)
Please Select
Please Select
Male
Female
Sex/Sexo
Please Select
Please Select
Yes/Si
No/No
Licensed?
Please Select
Please Select
Yes/Si
No/No
Microchipped?
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OTHER PETS
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I certify that the information provided in this application is true, to the best of my knowledge. I understand that giving false information will result in denial of the application.* This field is required.Certifico que la informacion proporcionada en esta solicitud es verdadera, a mi leal saber y entender. Entiendo que dar información falsa resultará en la denegación de la solicitud.
Clear
33
I have read and understand all the guidelines for participation in the Kings County Animal Services Pet Pantry food assistance program. I agree to follow all guidelines set forth, or my participation in the program will be denied. Kings County Animal Services has the right to not give food to anyone under any circumstances.* This field is required. He leido y entiendo todas los pautas para participar en el programa de asistencia alimentaria de la despensa de mascotas de los Servicios para Animales del Condado de Kings. Acepto seguir todos las pautas establecidas, o mi participación en el programa será denegoda. Servicios para Animales del Condado de Kings tiene el derecho de no dar comida a nodie bojo ninguna circunstancia.
Clear
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DateFecha
Date
Month
Day
Year
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Print name of ClientEscriba el nombre del cliente
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