Apply for Pet Food & Basic Care - PALS - Pets Are Loving Support

PALS Application: Pet Food & Basic Care

Please complete this application and submit with most recent Social Security letter or tax return, state issued ID, utility bill with address matching ID, and any veterinarian records you have.
(The information contained on this form will be kept CONFIDENTIAL)

Section 1: Basic Information

Name(Required)

First Middle Last

Gender(Required)

Male

Female

Non-Binary

Date of Birth(Required)

Address(Required)

(Street Address/Do not use a P.O. Box)

Street Address / Apt # City ZIP / Postal Code

County(Required)

Telephone(Required)

Email(Required)

Area, Neighborhood or Building Name in which you live:(Required)

Is a code required if pet food is delivered?(Required)

Do you have transportation?(Required)

Yes

No (PALS does not provide transportation to clinic appointments or guarantee delivery of pet food)

How did you hear about PALS?(Required)

Section 4: Emergency Contact

Contact(Required)

First Last

Relationship to you(Required)

Phone (Home)(Required)

Phone (Work)

Section 4: Verification of Eligibility

To register as a client of Pets Are Loving Support, Inc. (PALS), please attach verification of the following:

1. Proof of Georgia Residency(Required)

Georgia Driver’s License AND utility bill or rental agreement.

Drop files here or

Max. file size: 100 MB, Max. files: 2.

2. Proof of Income less than $30,00 per year(Required)

SSI and/or SSD award letter or recent tax return.

Drop files here or

Max. file size: 100 MB, Max. files: 2.

3. Proof of Medical Disability & Diagnosis(Required)

Physician's letter confirming disability and/or critical illness.

Drop files here or

Max. file size: 100 MB, Max. files: 5.

4. Proof of Spay/Neuter

Certificate or letter issued by veterinary.

Max. file size: 100 MB.

Proof of Pet Ownership(Required)

The most recent veterinary record stating your name and the name of your pet(s).

Drop files here or

Max. file size: 100 MB, Max. files: 2.

Section 5: Consent to Release Information/Statement of Fact

Client Signature(Required)

Date(Required)

PALS CLIENT DEMOGRAPHIC INFORMATION

We are often asked by private foundations for demographic information about our clients. The following will be used for grant applications and will not be considered as a part of your application to join our program. Your name or other personal identifying information will not be disclosed. We appreciate your assistance in helping us secure funding by providing this information.

Ethnicity(Required)

Date of Birth(Required)

Gender Identity (male, female, Non-binary)(Required)

Sexual Orientation (heterosexual, gay, bi-sexual, prefer not to answer)

Veteran Status(Required)

Client Service Agreement

(must be checked and signed by applicant)

I, ________________________ have been informed that in order to continue to receive services from Pets Are Loving Support, Inc. (PALS) that it is necessary that I comply with the terms of this Service Agreement.(Required)

Name

Please check each of the following lines:

Signed(Required)

Date(Required)

PALS, 1530 DeKalb Avenue NE, Suite A, Atlanta, GA 30307 | 404-876-7257 | [email protected]

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PALS Application: Pet Food & Basic Care

PALS Application: Pet Food & Basic Care

Section 1: Basic Information

Section 2: Health Information

Section 3: Housing

Section 4: Emergency Contact

Section 4: Verification of Eligibility

Section 5: Consent to Release Information/Statement of Fact

PALS CLIENT DEMOGRAPHIC INFORMATION

Companion Animal Information (Pet 1)

Companion Animal Information (Pet 2)

Client Service Agreement

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