Pet Food Pantry Application for Assistance and AgreementName of person requesting assistance(Required) First Last PhoneAddress(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is anyone in your home a veteran, senior citizen, or receiving social security disability income?(Required) Veteran Senior citizen Receiving Social Security None of the aboveNumber of veterans(Required)Number of senior citizens(Required)Persons receiving Social Security disability(Required)How many dogs do you have at home?(Required)Please enter a number from 0 to 100.How many cats do you have at home?(Required)Please enter a number from 0 to 100.How many puppies do you have at home?(Required)Please enter a number from 0 to 100.Are all of your pets spayed or neutered?(Required) Yes No N/APlease list by name, species and age any that are not altered.(Required)Are you going to spay or neuter them in the future?(Required) Yes No N/AAre you trying to rehome any of your pets?(Required) Yes NoIf yes, which pet(s) and reason why is rehoming necessary:Please describe the reason you are requesting assistance at this time.(Required)Will this reason change any time soon?(Required)Agreement(Required) I agree to the ARF Pet Food Pantry AgreementBy my signature below, I agree: 1. To not to sell, give away, or return to a store any pet food or supplies received from the ARF Pet Food Pantry. 2. That I am the owner of or the person legally responsible for the pets for whom I am requesting assistance. 3. To have my pets spayed and/or neutered within three months of receiving pet food assistance. 4. To not acquire additional pets while I am receiving assistance. 5. That pet food I receive may not be the brand I normally feed my pet(s). I understand my pet may become ill from changing brands of food. 6. That the pets for whom I am asking assistance are considered part of the family and live with inside shelter in healthy living conditions. 7. That I have read the ARF pet food Pantry guidelines and understand what I have read. 8. To return any unused food or supplies I receive to ARF. 9. To hold ARF, its volunteers and benefactors harmless for any illness or decline in the health of my pets.Signed by(Required)Date(Required) MM slash DD slash YYYY
