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Application for pet food assistance
Before completing this application please review all requirements. Make sure that you have your supporting documentation prepared (removing identification numbers such as drivers license number or social security number) to submit via email (
apps@lovebugfoundation.org
) or fax (404-419-6349) one you have completed this form. Failure to provide the supporting documentation will result in your application being declined.
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* Indicates required question
General information
Applicant name
*
As it appears on identification and supporting documentation
Your answer
Date of birth
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MM
/
DD
/
YYYY
Mailing address
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Your answer
Telephone
*
Your answer
Email
*
Your answer
I meet the following criteria for assistance:
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Senior citizen
Disabled
Veteran
Required
Reason you are applying for assistance
*
Your answer
I confirm that I have not been convicted of any crime, misdemeanor or felony, against an animal; and, give permission for love bug foundation inc. to verify this via a background check. Please type your initials in the box below.
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Your answer
Pet information
I am applying for:
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Choose all that apply.
Cat food
Dog food
Required
Pet information # 1: Please list the name, age, sex, weight and species of the pet
*
Your answer
Pet information # 2: List the names, age, sex, weight and species of the pet
*
Type "none" if you only require food for one pet.
Your answer
I certify that the animals listed above are current on vaccinations and have been spayed/neutered and will provide documentation to confirm such. Please type your initials in the box below.
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Your answer
Provide veterinarian name/clinic name and telephone number
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Your answer
I confirm that I maintain healthy living conditions for my pet(s) and welcome a home check if required. Please type your initials in the box below.
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Your answer
How did you hear about us?
*
Your answer
Waiver
By submitting this application, I understand that love bug foundation inc. cannot be held responsible for any illness, injury or death of my pet(s) resulting from the consumption of any food(s) received. I further confirm that all information provided on this application is correct. Please type your full name in the box below to acknowledge this waiver.
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
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