Pet Food Support Application
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you the owner of the pet you are making this application for
Yes
No
If you are not the owner please explain your connection with the pet
Are you in receipt of benefits
Yes
No
Please tell us why you need assistance
Name, breed & gender of each pet in need of support
How long have your pets lived with you
Name & Address of Vet Practice you are registered with
Does your pet have any special dietary needs or allergies (we are unable to supply raw food)
Which of the following do you need
Dry Dog Food
Dry Cat Food
Cat Litter
Wet Dog Food
Wet Cat Food
Do you need help with parasite treatments?
Yes
No
Is your pet spayed / neutered
Yes
No
Do you agree not to resell or give away the items we provide
Yes
No
Would you have to rehome or surrender your pet to rescue without this service
Yes
No
Do you agree to provide evidence of low income
Yes
No
How did you hear about our pet food support service?
Our services are subject to availability & strictly offered on a one week supply basis
I understand
Please confirm that you are not a breeder
No I am not a breeder
I am a breeder
Do you give us permission to use the photograph of your pet /pets in our advertising and agree that you will not receive financial compensation for allowing us to do this
Yes
No
Do you understand that we rely on donations to provide food to you which is limited to availability. We can only offer you what we have at the time of application, this may be a different brand than your pet normally eats
Yes
No
Name Of Human Food Bank You Are Currently Using
Is there anything else you would like to tell us
Please upload picture of the pet/pets needing support
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