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APPLICATION FOR FUNDING ASSISTANCEGUARDIAN INFORMATION*Date:____________ *Name:_________________________________ *Address:______________________________ *City:_________________ *State:____ *Zip:_______ *Home Phone / Area Code:_____________________ *Work Phone / Area Code:_____________________ *eMail Address:_____________________________ *Cell Phone / Area Code:_____________________ *You are the Cat/Kittens: _____Guardian ____Rescuer _____Good Samaritan. *What Factors Qualify You For Assistance? __________________________________________ CAT/KITTEN INFORMATION*Name of Cat/Kitten:_________________________ *Diagnosis:__________________________________ *Required Treatment:_________________________ _____________________________________________ *Date Treatment Must Begin:_____________________ *Has Treatment Started?____ *Been Completed?:___ *If Yes, Please Explain:_____________________ *Prognosis:_________________________________ *Estimated Cost of Treatment:_____________ TREATING VETERINARIAN INFORMATION*Name:______________________________________ *Address:___________________________________ *City:_________________ *State:_______ *Zip:___________ *Phone Number / AreaCode:____________________ *FAX / Area Code:_____________________________ *EMail Address:_______________________________ GUARDIAN STATEMENTI attest that I am responsible for the above cat/kitten and that all information provided is true and accurate. I understand that the FVEAP assumes no responsibility for the outcome of any treatment funded by the FVEAP. I also agree to provide any additional information requested and pictures of the cat/kitten for use in fund-raising. *Signature:____________________ |
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: Application