Name of treating veterinarian: ______________________________________________________________________
Address:______________________________________________________________________________________
Telephone number: _________________________________ Total estimated veterinary bill: _____________________
Amount of assistance requested: ___________________________ Gross family income: ________________________
Please describe the type
of injury/illness and how it occurred:
__________________________________________________
__________________________________________________________________________________
Please detail any
extenuating circumstances that you wish the Board of Directors to consider when
making its determination:
______________________________________________________________________________________________
__________________________________________________________________________________
If approved, I am willing to allow the BEHAF Board of Directors to use
the following information from my case for the purposes of public education, fund raising, or other
official use as deemed appropriate by the Board. (Please list - for example: name, address, medical condition,
story of dog's illness/injury, etc.)
__________________________________________________________________________________
__________________________________________________________________________________
I certify that the above information is accurate to the best of my knowledge. I further certify that I am the owner of the dog identified above and am applying for assistance from BEHAF for medical expenses for treating that dog. I understand that I may not be approved for assistance and that the decision of the BEHAF Board of Directors is final. I further understand that BEHAF encourages the repayment of assistance through monetary contributions and/or volunteer work.
Signature: ___________________________________________________ Date: _____________________________
Date received: _________________________________ Mailed to Board:
_____________________________________
Financial data: _________________________________ Photo received:
______________________________________
Veterinary
certificate: ___________________________ Amount requested:
___________________________________
Approved:
________ Disapproved: __________Date:
_____________________
Notification to applicant - Date: ______________ By: ____________________________
Check amount: _____________ Number: _____________ Date: _____________ Date mailed: ________________
Application - page 1 | Application - page 3
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