* ALL FIELDS REQUIRED

If a question does not apply to you, fill in the blank with "NA"

* 1. Name: (First and Last)

* 2. Address:

* 3. City:

* 4. State:

* 5. Zip Code:

* 6. Home Phone: (xxx-xxx-xxxx)

* 7. Cell Phone: (xxx-xxx-xxxx)

* 8. Work Phone: (xxx-xxx-xxxx)

* 9. E-mail:

* 10. Names and Ages of other people in home:

* 11. Your Employer/Occupation:

* 12. Your Yearly income:

* 13. Is any other resident of your household employed?

* 14. Others Employer/Occupation:

* 15. Others Yearly income:

* 16. Please describe the situation for which you are applying for assistance:

* 17. Please itemize what you estimate will be the total expenditure for the rescue,
and be prepared to provide receipts and/or estimates on official letterhead from each provider for whatever you are submitting:

* 18. Please provide the name, address and telephone number of your current veterinarian
or the one who is involved in this rescue, if applicable:

* 19. Please provide the name, address and telephone number(s) of any other individual(s) involved in this rescue:

* 20. How did you hear about The Rescue Fund?:

* 21. Are you affiliated with any sanctuary and/or rescue organization? If so, which one(s)? :


* 22. Are you a 501(c)(3) or otherwise affiliated with one? If so, which one(s)? please give EIN#:


I attest that the preceding answers and information are true and correct to the best of my knowledge and information. I will provide in a timely manner whatever other information is deemed necessary by The Panel to make its decision.

* Signature Date (mm-dd-yyyy)