Application for Assistance

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email *

Pets in Your Home

How many pets are in your household? *

Complete for ALL pets:

1. Pet Name *

1. Pet Type *

Dog
Cat

1. Age (years) *

1. Weight (lbs) *

2. Pet Name *

2. Pet Type *

Dog
Cat

2. Age (years) *

2. Weight (lbs) *

3. Pet Name *

3. Pet Type *

Dog
Cat

3. Age (years) *

3. Weight (lbs) *

4. Pet Name *

4. Pet Type *

Dog
Cat

4. Age (years) *

4. Weight (lbs) *

5. Pet Name *

5. Pet Type *

Dog
Cat

5. Age (years) *

5. Weight (lbs) *

Do any of your pets require special diets? *

Yes
No

Can your pet(s) eat dry food? *

Yes
No

Will you or do you breed your pet(s) for sport or profit? *

Yes
No

Have you received assistance from us before? *

Yes
No

How did you hear about us?

To be considered for assistance, you MUST agree to the following and initial below each:

Be the pet's owner *

Be 18 years or older *

Have a picture ID with your current address each visit *

Provide proof of need (SS letter, Medicaid card with date or letter, unemployment letter, referral letter, food stamps letter) *

Provide verification that ALL pets have been spayed/neutered. Noncompliance will result in removal from the program. (At least one pet each month until ALL have been spayed/neutered. Bi-State offers financial support, please ask) *

Provide verification that ALL pets have current rabies vaccinations *

Have had your pet(s) for at least 6 months *

Agree to complete a new application if you move or if the number of pets in your household changes *

Understand the food provided is donated and may not be your current brand, which may upset your pet's stomach (it is best to mix the donated food gradually to your current food) *

Agree NOT to hold Bi-State Pet Food Pantry, its staff, volunteers and benefactors legally liable in the unfortunate event your pet(s) become ill or the food upsets the pet's stomach *

Agree NOT to resell anything received from Bi-State Pet Food Pantry *

Agree that you do NOT breed any of your pets for profit or for sport *

Agree that you will NOT add animals to your house if receiving assistance. We will no longer provide assistance if you do *

Understand that Bi-State Pet Food Pantry has the right to deny your application *

Understand that the Pantry reserves the right to take pictures to use for their marketing materials, web page and social media sites *

Signature *

Date *