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APPLICANT INFORMATION

Full Name
Address
Name Of Spouse
Are there other members of your household you would like to assign to be able to pick up food if you are not available?
Pet owners who qualify must be receiving one of the following forms of assistance. Please indicate what form of assistance and upload the noted documentation.

OR

Experiencing financial hardship such as:
Click or drag files to this area to upload. You can upload up to 5 files.

PET INFORMATION

Pet Number 1

I certify that all of the above information listed is true and correct.  I understand that I may be disqualified from receiving assistance by making false statements or from the withholding of documentation.  I hereby authorize Appalachian Highlands Humane Society to obtain and/or release any information from and to any source pertaining to my request for assistance.  Appalachian Highlands Humane Society enters all gift data or gift denials into the Carity Check system as well as the information provided on the application.  I understand that my photo or photo ID may accompany my information in Charity Check.  This is a data sharing network in cooperation with churches and human service agencies.   THIS AUTHORIZATION DOES NOT EXPRIE UNLESS REQUESTED IN WRITING.

*All information provided is used only to determine your need for pet food.  All information must be completed to receive assistance.  Incomplete applications will not be accepted.

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