Please provide the following Organization Information:

Your name:

Your email: (please use an email address you are able to check often)

Your phone numbers:

DAY                    EVE

Name of Organization:

Type of Organization: Pit bull and/or Amstaff Rescue Foster Home All Breed Animal shelter Independent Foster Other

If you have chosen other please state:

Are you part of a not-for-profit 501(c)3 organization? yes no

Mailing address for organization:

Street Address
Address (cont.)
City
State	Please choose one of the following:- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territory Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip/Postal Code

Email and website for organization:

Email:

Website:

Day phone contact number:

Evening phone contact number:

 

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*How many animals are in your care now?

General information related to the case:

*Please tell us about your financial situation and why you are asking for help. The more details you provide, the easier it will be to process your request. If we don't have enough information, we will contact you.  This will delay the process and could impact when the decision is made for your case.

          *What is your dog's name?

          *What is the age of your dog?

0 to 3 Months 4 to 8 Months 9 to 18 Months 19 to 36 Months 3 to 5 years Over 5 Years

*Gender of dog:-

male female

*Is your dog spayed/neutered?

yes no

*What is the breed of your dog?

Pit Bull (APBT American Staffordshire Terrier Pit Bull Mix

*Is the dog residing with you, if so for how long?

*Where did you get the dog from?

          Rescued from an abusive situation Pulled from shelter Owner turn over From a friend or relative Stray other

*Has the dog been temperament tested? yes no

*Did the dog pass? yes no

*Is the dog listed for adoption, if so where, (please include link if applicable?)

*Is the dog current on vaccines, including heartworm preventive medication and rabies?

yes no

*What is the diagnosis of the medical problem?  Please be specific and enter in the space below:

*Are you able to foster this dog during treatment and until a suitable home is found?

*Name and address of vet or animal hospital from which estimate was received

*Contact person for your dogs case, phone and/or fax number:

*Does the vet/contact person have email and/or website?

          yes no

*If your answer to the question is yes please list the details:

*What is the cost quoted on the vet's estimate?

*How much of this have you already paid or plan on paying during or after treatment?

*It is rare that PBRC has enough funds to cover the full amount needed in most cases. What amount will you contribute?

*After your contributions and other donations pledged at this point, what is the balance due or what is the anticipated balance due?

*Based on advice from the vet, how urgent is it for the dog to receive the care it needs?

          Very urgent: condition is critical Not critical, I have time to do fund raising Nor critical, but dog is in pain

*Do you already have an appointment scheduled for this veterinary care?

          yes no

*If you have answered "yes" please list when:-

-- mm/dd/yy

*What is the prognosis for your dog after receiving care for this diagnosis?

*Does your dog have any other medical condition?

          yes no

*If you have answered "yes" please specify:-

*Have you applied to any other sources for the help you need, i.e. Care Credit?

yes no

*If you have contacted other sources please use the space below to tell us 1) who you have contacted, 2) phone number and, 3) results:

*How many other pets do you have?

*Additional comments you'd like to share with the fund committee members?