Thank you for contacting Petey’s Promise. Please fill out this application so we can determine if you’re eligible for assistance. Please answer each question truthfully. All information given is kept strictly confidential. Any false information on this application will result in the disapproval of this application and assistance will be denied.

In order to be considered for assistance, you must:

Be 18 years and older. *

Have picture ID with your current address. *

List the names of all household members 18 years and older. *

If the number of pets change in your household or you move, you agree to fill out a new application. *

Understand the food provided is donated and that it may not be your current brand, therefore your pet(s) could get an upset stomach due to the introduction of a new food to their diet. *

Agree to hold Petey’s Promise, its staff, and volunteers free from all legal action and are aware of the risks involved with feeding your pet a new food. *

Agree you do not breed any of your pets or animals for profit or sport. *

Understand Petey’s Promise has the right to deny your application. *

Agree by receiving food from Petey’s Promise, to give a food or monetary donation back to the foundation at distribution or when you are able to. *

By typing your name below, you understand and agree to all of the provisions above. Typing your name will be regarded as a temporary signature. If your application is accepted, you will be required to sign a form on your first pick up.

Full Name *

Date mm/dd/yyyy *mm/dd/yyyy *

*All fields are required*

Full Name *

Address *

Address (optional)

City * State *

ZIP *Invalid format.

Phone # (000) 000-0000 *

Email Address Invalid format.

Number of Household Members *

Names of family members over 18 (separate names with commas)
*

Number of Pets in Household *

Please list all pets including their names, type, breed, age and size.
Please enter each animal's information on a separate line.
Petey, dog, Lab-Spaniel mix, 7, large. Madison, cat, American Shorthair, 12, medium. *

Are any of the pets named above used for breeding?

Yes
No
*

If yes, for sport?

Yes
No
*

How did you hear about us? Select One Newspaper Advertisement Internet Search Social Networking Site (Facebook/Twitter) Referral Other *

If other, please specify

Have you received assistance from us before?

Yes
No
*

If yes, when?

If you brought your pet(s) with you, would you allow us to take a photo of your pet(s) or you and your pet(s), to be used for advertising purposes? If yes, by signing below one agrees to relinquish all rights for monetary gain and compensation.

Yes
No
*

I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND THAT GIVING ANY FALSE INFORMATION WILL RESULT IN THE DISAPPROVAL OF THIS APPLICATION AND DISQUALIFICATION OF FUTURE APPLICATIONS. Typing your name will be regarded as a temporary signature. If your application is accepted, you will be required to sign a form on your first pick up.

Full Name *

Date A value is required.mm/dd/yyyy *