Apply for Assistance

Before you begin please gather the following information for use in your application.

  • Your Driver’s License number
  • Your Social Security number
  • Contact information for 1 personal reference
  • Your Veterinarian’s name and contact Information
  • Dates of your pet’s last vaccinations
  • Income information for each member of your household

Please fill out all information or your application cannot be considered.

You can also download the printable form in English or Spanish and send it to info@animalwelfare.com for consideration.

About You

Name
Residential Address
City
Zipcode
Mailing Address
City
Zipcode
Home Phone
Cell Phone
Work Phone
Email
Social Security Number
Drivers License Number / State

About Your Veterinarian

Current Veterinarian's Name
Veterinarian's Address or Phone Number
Do we have your permission to get records from your veterinarian?

Personal Reference

Name
This person is my:
Residential Address
City
Zipcode
Mailing Address
City
Zipcode
Home Phone
Cell Phone
Work Phone
Email

Pet Information

Pet Name
Dog / Cat Breed
Sex
Date of Birth or Approximate Age
Is pet Spayed / Nutered?
Date of last Rabies vaccination
Is pet microchipped?
What is your pets current problem?
Has the pet ever had surgery before?
If Yes, for what?
Please list any problems the pet had with surgery?

Financial Information

Have you received assistance from A.W.I.A. in the past?
If Yes, When?
Was it for the same animal as now?
What type of Assistance did you receive?
If a Loan, when was it paid off?
Are you currently employed?
If yes, name, address, phone number of employer:
If not Employed, date last worked:
Last Employer
Do you own your home?
How many people in your household?
Amount of monthly income for each person in the household, including child support, spousal support, etc.
Do any of the adults have any investments?
If yes, what?
Are you a disabled veteran?
If yes, percent of your disability?
Is your dog a trained service animal?
If yes, what tasks has it been trained to perform:
Do you currently recieve Cal Fresh or SNAP (Food Stamps)?
Do you currently Social Security Disability or SSI?

Your Signature

By typing my full name here, I certifies that all of the above information is true and correct and that I am the legal owner of the pet described above.

Full Name Date