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)AddressTown/CityStateZipPrimary PhoneCountryEmail Adresss OccupationEmployer 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) Pet1NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromPet2NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromPlease 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: 2 GB. Date MM slash DD slash YYYY CSPCA Staff SignatureAccepted file types: jpg, png, Max. file size: 2 GB. Date MM slash DD slash YYYY Pets at Home Please fill out for every remaining pet in the home How Many DogHow Many CatPet1NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered?Pet2NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered?Pet3NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered?Pet4NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered?Pet5NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered?Pet6NameSpecies/ BreedAgeColorSexMaleFemaleWhere did pet come fromIs pet already Spayed/Neutered? Δ Download PDF Adoption Application PhoneThis field is for validation purposes and should be left unchanged.To ensure your application is properly submitted, please read the following:*Make sure to answer ALL questions on the application. If a question does not apply to you, please enter "0" or "NA"! You will be taken to a confirmation page after your application has been successfully submitted!Adoption FeesDog: $155; Cat: $100; Adoption fees are currently waived thanks to the Safe Haven Fund!Which animal you are looking to adopt?*If you're not applying for a specific animal, please type "none."Is the animal a cat or dog?* Cat Dog Personal InformationName* First Last Spouse's or Significant Other's Name First Last Date MM slash DD slash YYYY Phone*Physical & Mailing Address* Street Address City 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 State ZIP Code Email* Employer*Occupation*Spouse's or Significant Other's EmployerSpouse's or Significant Other's OccupationDo you own your home?*YesNoDo you own the land your home is on?*YesNoWhat is your landlord's name? First Last Landlord's Phone NumberAre you over the age of 18?*YesNoDo you plan to move in the next 6 months?*NoYesPrior & Current Pet InformationPlease list ALL the pets you currently have in your home:*Please include name and species, as well as any pets that belong to anyone who lives with you, or who comes and stays for any significant period.This field is hidden when viewing the formAre they currently all spayed/neutered Yes No This field is hidden when viewing the formAre they currently up to date on their vaccination* Yes No This field is hidden when viewing the formHave you ever surrendered an animal to the shelter?* Yes No This field is hidden when viewing the formList of the pets you have previously owned, in the last 10 years.*Include: reason why you no longer have the animal. Veterinarian's Name:*Phone Number of Veterinarian's Office:*General InquiresDo you have any children in your home?* Yes No What are their ages?*Please list anyone else that resides with you or stays for an extended period of time.*On average, how long will the pet be alone during the day?*This field is hidden when viewing the formHow do you plan to deal with behavioral issues if they arise?Dog-Specific QuestionsComplete these questions only if you're applying to adopt a dog. How is the dog going to be confined to your property?This field is hidden when viewing the formHave you owned a dog in the past? Yes No This field is hidden when viewing the formHave you adopted a dog from a shelter in the past? Yes No This field is hidden when viewing the formAre you familiar with crate training? Yes No This field is hidden when viewing the formAre you familiar with house breaking? Yes No Is this going to be an indoor or outdoor dog? Indoor Outdoor Both This field is hidden when viewing the formAre you familiar with grooming needs? Yes No Cat-Specific QuestionsComplete this portion only if you're applying to adopt a cat.Is this going to be an indoor or outdoor cat? Indoor Outdoor Both This field is hidden when viewing the formDo you plan on declawing? Yes No This field is hidden when viewing the formHave you adopted a cat from a shelter in the past? Yes No This field is hidden when viewing the formAre you familiar with grooming needs? Yes No This field is hidden when viewing the formPart 6-Personal References ( NON FAMILY)List 2 non-family personal references.This field is hidden when viewing the formName* First Last First ReferenceThis field is hidden when viewing the formPhone*First referenceThis field is hidden when viewing the formRelationship*First referenceThis field is hidden when viewing the formName* First Last Second ReferenceThis field is hidden when viewing the formPhone*Second ReferenceThis field is hidden when viewing the formRelationship*Second ReferenceCertificationMUST READ* I agree to these terms.I certify that the above information is accurate and complete to the best of my knowledge. I understand that the CSPCA has the right to reclaim the animal if any given information is found to be false. I authorize the release of veterinarian information related to my current and past pets. I understand the costs associated with owning a pet, that these costs can range from $400-800 annually, and that there may be additional costs due to injury or illness. Photo ID may be required.Sign Here:Online Signature*Please type your full name confirming that you have read and understand the above statement.This field is hidden when viewing the formOnline Signature-ErrorPlease type your full name confirming that you have read and understand the above statement. Look for our confirmation page to ensure your application was submitted correctly!Once you complete the application and submit, you will be redirected to a confirmation page.This field is hidden when viewing the formRef 1- Do you think they are exceptional pet owners? Yes No This field is hidden when viewing the formRef 1- Would you trust them to watch your pet if you were away? Yes No This field is hidden when viewing the formRef 2- Do you think they are exceptional pet owners? Yes No Δ Our Proud Sponsors and Partners
