Application for Assistance

Email *

Today's Date

Your Spouse's Employer (Name and Address) *

Your Spouse's Length of Employment

If request is for medical assistance, how much can you afford to contribute at this time?

Type of assistance requested and reason (please explain) *

If the veterinarian is willing to offer a payment plan, will you take advantage of this option?

Yes

If no, why?

Home Mailing Address *

Your Name: *

Home Phone *

List any Government Assistance *

Check box *

By checking this box, I certify that the above information is true. I understand any pet care assistance I may receive will be provided to my pets based on the information above. I understand in order to receive pet care assistance I must be a resident of Moffat County.

Number of dependents (including self/spouse) *

"helping the pets of Moffat County since 2002"

Application for Assistance

Contact Information

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