Love For Animal Registration Form

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Name* This field is required.NAME OF THE PERSON RECEIVING BENEFITS
First Name
Last Name
2
Email* This field is required.PLEASE CHECK YOUR EMAIL CONSISTENTLY UNTIL YOU RECEIVE A CONFIRMATION EMAIL FROM US
example : loveforanimal404@gmail.com
Confirm Email
3
Address* This field is required.PLEASE ONLY PROVIDE YOUR CITY, STATE AND ZIPCODE
PLEASE SKIP TO CITY , STATE AND ZIP CODE
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.PLEASE PROVIDE A NUMBER WE CAN TEXT OR CALL
Area Code
Phone Number
5
Select All That Apply* This field is required.PLEASE SELECT IF ANY OF THESE HAPPENED WITHIN THE LAST 12 MONTHS
Unemployed
Recently Had A Baby
Added an Additional Pet
Relocated / Moved Into a New Place
Needing Help Due to Inflation
Pet food is too expensive to
NONE APPLY
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Select All That Apply* This field is required.PLEASE SELECT RESOURCES YOU NEED
Dog Food and Treats
Cat Food and Treats
Other Animals : Bird, Farm Animals, Reptile, Fish Food and Treats
Dog Essentials i.e. Shampoo, Pet Bedding, Dental Care, Toys, Collar/Leash Set, Flea and Tick
Cat Essentials i.e. Shampoo, Pet Bedding, Dental Care, Toys, Collar/Leash Set, Flea and Tick
Other Animals : Bird, Farm Animals, Reptiles, Fish Dog Essentials i.e. Shampoo, Pet Bedding, Dental Care, Toys, Collar/Leash Set, Flea and Tick
Pet Garments (Clothes, Shoes, Rain Jacket)
Human Essentials (Body wash, Feminine, Pads, Diapers etc.)
Resources i.e. Dog Training, Vet Services, etc.
7
Don't See What You Need ??IF YOUR SELECTION IS NOT LISTED PLEASE SHARE WHAT YOU NEED. IF YOU SELECTED "RESOURCES" PLEASE EXPLAIN WHAT IS NEEDED
8
Select Your Pet Type* This field is required.SELECT ALL THE SPECIES YOU CURRENTLY TAKE CARE OF
Dog
BIrd
Cat
Reptile
Hamster
Ferret
Exotic Pet
9
How Many Pets In Home * This field is required.Please place all the number
10
If You Selected Exotic Pet Please Provide Type of Pet TYPE N/A IF NOT APPLICABLE
11
Are You Requesting Food Emergency Package For All The Pets You Selected * This field is required.WE WILL ONLY PROVIDE ASSISTANCE TO THE PETS YOU WANT US TO HELP WITH
YESNO
12
Please List The Names and Gender of All The Pets Receiving Assistance* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Future Appointment Availability * This field is required.
14
PLEASE PROVIDE A PICTURE OF YOUR PET * This field is required.PICTURE OF ALL ANIMALS REQUESTING A CARE PACKAGE
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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PLEASE SIGN THAT YOU AGREED ALL INFORMATION IS CORRECT* This field is required.
Powered by Jotform SignClear
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I UNDERSTAND THAT LOVE FOR ANIMALS REQUIRES ME TO PROVIDE PHOTOS OF MY PET BEFORE AND AFTER PICKUP. I ALSO UNDERSTAND I AM REQUIRED TO PROVIDE PICTURES OF MY PETS WITH THE PRODUCTS* This field is required.PLEASE SEND PICTURES TO OUR WEBSITE WWW.LOVEFORANIMALOUTREACH.ORG, EMAIL TO LOVEFORANIMAL404@GMAIL.COM OR DM US ON IG AT @LUV4PAW404
I AGREE
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I UNDERSTAND THAT IF MISSED MY PICK-UP APPOINTMENT AFTER 3 ATTEMPTS, I WILL HAVE TO RE-REQUEST A PACKAGE AND GET BACK IN LINE* This field is required.PLEASE KNOW THAT WE UNDERSTAND TIME GETS TO EVERYONE, PLEASE TELL THE PERSON IF YOU HAVE OR WILL HAVE ANY ISSUES WITH PICK UP SO WE CAN BETTER ACCOMENDATE YOU.
I Understand
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I UNDERSTAND LOVE FOR ANIMALS FIRST PRIORITY GROUP IS THE SERVICING COMMUNITY ZIP CODE (GO TO OUR WEBSITE WWW.LOVEFORANIMALSOUTREACH.ORG TO SEE OUR ZIP CODES).**** Donations are not required for service and will not determine your approval* This field is required.ALLOW TIME FOR THE YOUR REQUEST TO PROCESS AND SET UP APPOINTMENT TO PICK UP
I Understand
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I UNDERSTAND THAT MY REQUEST WILL TAKE UP TO 3-4 WEEKS TO PROCESS* This field is required.ALLOW TIME FOR THE YOUR REQUEST TO PROCESS AND SET UP APPOINTMENT TO PICK UP
I Understand
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I acknowledge that my donation is voluntary and not obligatory. I understand every contribution goes towards LFA's animal care packages and school curriculum program!* This field is required.ALL DONATIONS ARE AT YOUR OWN WILL, NO DONATION IS REQUIRED FOR SERVICE !
I Acknowlegde
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THANK YOU FOR REGISTERING AT THE LOVE FOR ANIMALSThe following screen gives you the option to donate to support our mission. BOTH PROGRAMS ARE SPONSORED BY MADDIE'S FUND #THANKSTOMADDIE. Special thanks to our partner, the Atlanta Humane Society.
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WANT TO HELP US KEEP GOING ??!!YOUR DONATION GOES TOWARDS ANIMAL CARE PACKAGE PROGRAM, RESOURCES TO
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