CCPRF Pet 66 Application

Your Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Are You Applying For An Emotional Support Animal?*

YesNo

An emotional support animal can provide comfort, companionship, and help with lonliness, but is not trained to perform specific tasks for their handler. Emotional support animals are not permitted in public establishmnts unless the establishments are pet friendly.

I understand that if adopting an emotional support animal, I will adhere to all program requirements, including training of the emotional support animal to the AKC Canine Good Citizen Certification

I agree

Has a medical professional recommended that an emotional support animal will be of benefit for you?

YesNo

Has anyone taken an animal away from you due to neglect or because of an abuse claim?*

YesNo

Are you currently employed?*

YesNo

If you work, how many hours a day or week do you work?*

What kind of work do you do?*

Are you currently a student or in college or trade school?*

YesNo

Please share any post-military service educational degrees and achievements

Do you have any pets at home?*

YesNo

Type a question

	Pet Name	Species	Gender	Spayed/Neuterd?	Current on vaccines?	Pet's Age
Pet 1
Pet 2
Pet 3
Pet 4

I agree to keep my adopted pet up to date on vaccinations and provide appropriate veterinary care*

I agree

I agree to keep up with all training requirements if adopting an emotional support animal*

I agree

Please list the people who are living with you, their age and relationship to you*

Do you understand that if approved, a home inspection may be conducted and you agree to a home inspection?*

I agreeI do not agree

We understand that this is personal information and may be difficult to share. Please understand that all information shared on this application is confidential, handled with care and is intended to help you gain acceptance into our program. The information assists us in getting to know you, your personal needs and if accepted, the details will assist us in matching you with a pet that will be the right fit for you. The more we know about you, the better our team can best understand how to assist you.

Branch of Service

Are you currently active duty?

YesNo

Are you currently reserve status?

YesNo

Are you medically retired?

YesNo

What is your DD-214 discharge status?

I understand that by being accepted into the Pet 66 program, I may be eligible for assistance and support for veterinary care, training, food and supplies*

I understand

I, First Name* Last Name* hereby declare that the details provided above are true and correct to the best of my knowledge and belief. Furthermore, I agree to inform the Comanche County Pet Resource Foundation of any changes therein, immediately. In any case whereby the above information I have provided to be false, untrue, misleading, or misrepresenting, I am aware my approval by the Comanche County Pet Resource Foundation, and the Pet 66 program, may be retracted, resulting in the immediate and permanent dismissal of ANY programs of services offered by Comanche County Pet Resource Foundation, or any affiliate companies. In any case whereby the above information I have provided is found false, untrue, misleading or misrepresenting, I am aware any program established within the Comanche County Pet Resource Foundation may be terminated without compensation. Signature*

Signature

Date

For Official Use

Application Approved

YesNo

If not approved, provide reason why application is denied

Adopted Pet's Name

Adopted Pet's Age

Adopted Pet's Breed

Adopted Pet's Sex

Vaccinations Current?

YesNo

Spayed/Neutered?

YesNo

Microchip Number

Training program enrollment needed?

YesNo