Kerby Flea Treatment Chenango SPCA Assistance Program Application KERBY Flea KERBY Flea Full Bellies Pet Food Pantry Full Bellies Pet Food Pantry Application InformationPlease Check One:*Public AssistanceLow IncomeP# Name* Other Household Members (Over the age of 18) Address Town/City State Zip Primary PhoneCountry Email Adresss Occupation Employer You must provide proof of Chenango Country Residency and proof of assistance . This agreement is not an automatic approval for funds. I am applying for FULL BELLIES and/or KERBY Flea for the following pet(s) Pet1Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Pet2Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Please read and check the follow items. By doing so, I acknowledge that I am applying for assistance for my pet(s) through one of the Chenango SPCA’s Assistance Programs and agree to the following:KERBY Flea I understand how to administer the medication I will follow the medication directions. I agree to use the medication ONLY on the animals that have been approved. I can receive 2 tubes at discounted rate ($4.00), and will pay the higher price ($8.00) for any additional tubes (maximum is 2 additional tubes). Full Bellies I understand that this program is only a temporary source of pet food. Any food given is intended for only my pets. If I acquire additional pets, my application will become void and I will not be eligible for further assistance by the CSPCA. I understand I can use the Full Bellies Pantry 3 times in a CALENDER year. Release of Claims Release of Claims: I release the CSPCA from any claims, liability or damage relating to any food or flea treatments I receive through the CSPCA Assistance Programs, and waive any right to raise false claims against the CSPCA related to these programs. If complications arise as a result of surgery or flea treatments, I agree to have my pet(s) treated by a veterinarian at my own expense I understand I understand that applying for assistance through the CSPCA will prohibit me from adopting from the CSPCA until I can prove that I am capable of financially caring for my pets. Applicant SignatureAccepted file types: jpg, png, Max. file size: 256 MB.Date MM slash DD slash YYYY CSPCA Staff SignatureAccepted file types: jpg, png, Max. file size: 256 MB.Date MM slash DD slash YYYY Pets at Home Please fill out for every remaining pet in the home How Many Dog How Many Cat Pet1Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Pet2Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Pet3Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Pet4Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Pet5Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Pet6Name Species/ Breed Age Color SexMaleFemaleWhere did pet come from Is pet already Spayed/Neutered? Δ Download PDF Our Proud Sponsors and Partners
