Fencing Assistance Application

The Animal Center accepts fencing donations from the public and gives them to citizens in need.

Name and Contact Information

Name*

First Name

Last Name

Date of Birth*

Date must be in format mm-dd-yyyy. (Example: 01-31-1980)

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone Number*

Enter the ten-digit phone number, including the area code. (Example: 123-456-7890)

Alternate Phone Number

Enter the ten-digit phone number, including the area code. (Example: 123-456-7890)

Email

Household Information

Number of Dependents in Home

Dependent's Name and Age

Legal Name of Spouse/Partner:

Income and Employment Information

Total Annual Household Income: $

Supplemental Income: $

Supplemental income may include food stamps, Medicaid, etc.

Are you currently employed?

Yes No

If employed, enter the name of your employer

Is your spouse/partner employed?

Yes No

If employed, enter the name of his/her employer

Property Information

Do you own your home?*

Yes No

If you do not own it, do you have permission by the homeowner to build on the property?

Yes No

NOTE: Written consent from the owner must be submitted.

Is the yard big enough to hold a 150 square foot pen?*

Yes No

I am applying for materials to reinforce an existing fence.

Yes No

I am applying for materials to build a new fence.

Yes No

Pet Information

Dog #1

Dog's Name

Dog's Age, Sex and Breed

Example: 4 years, Female, Yorkie

Describe the dog's weight, color and markings

Rabies Tag Number*

Date the Rabies shot was given*

I can provide a copy of the dog's Rabies certificate.*

Yes No

The dog is spayed or neutured. *

Yes No

The dog is/has:

Heartworm-positive and being treated Heartworm-negative Not been tested for Heartworm.

Veterinary Clinic Name and Address:

Dog #2

Dog's Name

Dog's Age, Sex and Breed

Example: 4 years, Female, Yorkie

Describe the dog's weight, color and markings

Rabies Tag Number*

Date the Rabies shot was given*

I can provide a copy of the dog's Rabies certificate.*

Yes No

The dog is spayed or neutured. *

Yes No

The dog is/has:

Heartworm-positive and being treated Heartworm-negative Not been tested for Heartworm.

Veterinary Clinic Name and Address:

I can complete the construction within 14 days of receiving the materials and understand that failure to do this can result in citations and fines. *

Yes No

I can provide vet records, proof of income and a letter from the owner of the property (if appropriate).*

True False

Please give any information that did not fit into the form that you would like to add.