Long Term Assistance Application

Long Term Assistance Application

For more than 2 months of disbursements
Date*

MonthDayYear
Date
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
# of Adults in home:*
# of Children in home*
Are there other members of your household that you would like to be able to pick up food if you are not available?*
*If yes, type the name of individual below. This person will need proper identification when picking up.
Alternate Pick Up Person:

First NameLast Name
Please list all pets in your home, with type, name, age, and weight so we can properly calculate food disbursment:*
Would you like information on Free/Low-Cost vaccination services?
Would you like information on Free/Low-Cost Spay/Neuter Services?
Would you allow No Empty Bowls to take a picture of your pet(s)and/or you to be used for advertising and fundraising purposes?*
*(If yes, please sign below. By signing, you agree that you are allowingNo Empty Bowls to use photos taken by No Empty Bowls for the purpose of fundraising and advertising, and that you will receive no monetary gain or compensation.)
Signature

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Are you receiving any of the following:*
*Need only check one of the above OR one of the below and provide adequate proof to qualify. Proof of one of these situations is required for long term assistance.
OR Are you:*
If you mark any of the options in the second dropdown menu, please use space provided below to explain your current situation.
Signature*

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Disclosures

Please read all information below.
- I understand that the goal of No Empty Bowls Pet Food Pantry is to provide food assistance to animal owners who are in financial need. Though we strive to provide adequate food for the applicant’s pets, there is no guarantee that No Empty Bowls will be able to meet the full nutritional needs of the applicant’s pets. Our aid is meant only as a stop-gap measure, not a complete food replacement. Supplementing food by the pet owner may be required.
- I understand that this aid is given on a case-by-case basis. and that No Empty Bowls is under no obligation to continue to aid if they are unable to do so.
- I understand that aid from No Empty Bowls is meant for the applicant’s personal companion animals within the home. Food/Supplies received from No Empty Bowls are not to be used to feed stray/feral animals or foster animals, nor is our aid to be used for TNR (Trap-Neuter-Release) or feral colonies within the community.
- Dog food, Cat food and supplies will only be provided within the limitations of donations received by No Empty Bowls. I understand that these donations have been received from individuals, businesses, and/or manufacturers and are not for sale to the public. I agree to use these donations only for personal companion animals within the home and will not resell these products to any individual or business. **Any person found to be reselling food or supplies given to them by No Empty Bowls will immediately be removed from program eligibility.**
- I understand that if for any reason my pet will not eat the food provided, I will return the food to No Empty Bowls for an exchange/replacement. I futher understand that food given away, without first speaking to a representative of No Empty Bowls, cannot be replaced.
- I understand No Empty Bowls assumes no liability and gives no guarantee for the food and supplies disbursed in any way.
- The information I have provided is true and correct to the best of my knowledge. I understand that any false information provided will result in my removal from eligibility for this service.
- By Signing this application, I agree I will hold harmless/indemnify No Empty Bowls and its affiliates from any direct, indirect, special, incidental, punitive or consequential damages, including but not limited to the injury to or loss of a pet which may arise from your decision to accept and use the food/supplies disbursed.
Signature*

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