Pet Food Pantry of Oklahoma | Qualified Assistance Application

Name of Applicant*

First Last

As of today, is the applicant over 65 years old?*

Yes
No

Is the applicant currently homeless?*

Yes
No

Applicant's total monthly income*

Name of other person(s) living in the home

Their age

Their total monthly income

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email

Is the applicant a U.S. Veteran?*

Yes
No

Proof of income for all those living in the home must be sent with your application. Applications cannot be processed without this information. **If you are a veteran, please send proof of military service.

In case of emergency, contact this person*

First Last

Phone*

Will you allow us to use your first name/story in our newsletter?*

Yes
No

What are the circumstances that have caused you to need our help?*

How did you hear about the pantry?

What agency referred you?

Please indicate your agreement with the following statements by checking "I agree" after each one.

I agree to feed and give fresh water to my pet(s) every day.*

I agree

I understand I will receive a supply of dog and/or cat food for my family pet(s) only - as listed on this application.*

I agree

I agree that pets are for companionship, not for breeding or any illegal activities.*

I agree

I agree no one in my household will resell food or items provided by PFPOKC.*

I agree

I agree to attend to my pet(s) in a timely manner if they need medical care (including yearly vaccinations) and to maintain healthy living conditions for my pet(s). I agree to let someone know if this is not possible.*

I agree

I agree not to tether or chain any of my pet(s) 24 hours a day, 7 days a week.*

I agree

I understand PFPOKC strives to meet special requests for food but are only able to give what they have at the time of service.*

I agree

I understand that PFPOKC will provide pet food on a first come, first served basis; as available.*

I agree

I understand this program is meant to supplement my pet’s food and may not fulfill the dietary needs of my pets(s).*

I agree

I agree not to add to my number of pets by taking in more animals.*

I agree

I understand my pet(s) must be spayed or neutered; I agree to provide proof and authorize PFPOKC to contact my veterinarian. We provide referral services for low-cost spay/neuter/vaccinations for pets.*

I agree

I understand PFPOKC reserves the right to terminate or deny any pet owners from this program.*

I agree

I understand PFPOKC will review my situation every 6 months.*

I agree

Pet(s) Profile – Please list all pets requiring food.

Pet 1 Details

Pet's Name*

Type of Pet*

Dog
Cat

Male or Female?*

Male
Female

Approximate age*

Is this animal current on its shots?*

Yes
No
I don't know

Is this animal spayed or neutered ("fixed")?*

Yes
No
I don't know

Approximate weight*

Does this pet need outside shelter?*

Yes
No

Pet 2 Details

Pet's Name

Type of Pet

Dog
Cat

Male or Female?

Male
Female

Approximate age

Is this animal current on its shots?

Yes
No
I don't know

Is this animal spayed or neutered ("fixed")?

Yes
No
I don't know

Approximate weight

Does this pet need outside shelter?

Yes
No

Pet 3 Details

Pet's Name

Type of Pet

Dog
Cat

Male or Female?

Male
Female

Approximate age

Is this animal current on its shots?

Yes
No
I don't know

Is this animal spayed or neutered ("fixed")?

Yes
No
I don't know

Approximate weight

Does this pet need outside shelter?

Yes
No

Pet 4 Details

Pet's Name

Type of Pet

Dog
Cat

Male or Female?

Male
Female

Approximate age

Is this animal current on its shots?

Yes
No
I don't know

Is this animal spayed or neutered ("fixed")?

Yes
No
I don't know

Approximate weight

Does this pet need outside shelter?

Yes
No

You are NOT ELIGIBLE to receive assistance from the Pet Food Pantry at this time. You must be homeless, a U.S. Military Veteran or over the age of 62 to receive assistance, and ALL pets in the household must be spayed or neutered.

To those who qualify, The Pet Food Pantry will provide pet food for up to 4 pets originally listed on the application. All pets must be spayed/neutered. For those not spayed/neutered, we will provide low-cost referrals.

Please attach a scan/copy of your proof of income.*

W-2, tax return, etc.

If you are a veteran, please provide proof of military service.

Please attach veterinary records showing proof that your pet(s) is/are spayed or neutered. All animals must be spayed or neutered.*

Who is your veterinarian?

First Last

Vet Clinic Name*

Veterinarian phone number*

Please type your name below to indicate your agreement with the following.*

I understand PFPOKC, its programs and its affiliates cannot guarantee the brand, type, or quality of the food given to me. If my pet(s) develops a medical condition in whole or in part by the food provided, I agree to release PFPOKC, this program, and its affiliates from all liability. I understand this program only supplements my pet food supply and I cannot depend on this program to fulfill the dietary needs of my pet(s). If my animals require prescription diets, PFPOKC will attempt to make these foods available. I understand that funds for this program are limited and in the event my current financial situation improves and I am no longer in need of this program, I agree to withdraw from the program so that the people most in need can be served. I agree to the terms of the program as stated above. By signing this, I agree that all information I have provided on this application is true.

Today's Date*

Please indicate your agreement with the following statements by checking "I agree" after each one.

Pet(s) Profile – Please list all pets requiring food.

Pet 1 Details

Pet 2 Details

Pet 3 Details

Pet 4 Details

To those who qualify, The Pet Food Pantry will provide pet food for up to 4 pets originally listed on the application. All pets must be spayed/neutered. For those not spayed/neutered, we will provide low-cost referrals.

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