PBRC FUND COMMITTEE

PBRC Dog Owner AID REQUEST FORM - Hurricane Katrina Victims

Instructions

PBRC is an internet-based organization. You must have access to a computer and e-mail, or we won’t be able to help. You must be able to check your e-mail on a daily basis for this service to be efficient. Allow a few days for your request to be processed. A member of the fund committee will contact you as soon as possible. All questions must be answered. If you do not know the answer, or it does not apply, please enter N/A. Applicant will be required to re-submit incomplete applications. There is a "comments" section at the bottom of the form for any additional information you may want to add. All correspondence should be sent to

These questions are for dog owners only. We have a separate application for fosters and dogs being held in a shelter pending adoption. If you are not the dog owner, please let us know and we will send you the correct form.

PBRC

What type of help are you requesting?

Please provide the following contact information:

*Name*
*Title*
*Street Address*
*Address (cont.)*
*City*
*State*
*Zip/Postal Code*
*Work Phone*
*Home Phone*
*E-mail*
*URL*

Occupation

*General information related to the case: Please tell us about your financial situation and why you are asking for help. The more details you provide, the easier it will be to process your request. If we don't have enough information, we will contact you. This will delay the process and could impact when the decision is made for your case.

*What is your dog's name?

*What is the age of your dog?

*Gender of dog:-
*Is your dog spayed/neutered?

*What is the breed of your dog?

*Where did you get the dog from?

*Please list details of where you got the dog, the name, location, etc. If they have a website please include the URL.

*How long have you owned the dog?

*Is your dog current on vaccines, including heartworm preventive medication and rabies?

*What is the diagnosis of the medical problem? Please be specific and enter in the space below:

*Name and address of vet or animal hospital from which estimate was received:

*Contact person for your dogs case, phone and/or fax number:

*Does the vet/contact person have email and/or website?

*If your answer to the question is yes please list the details:

*What is the cost quoted on the vet's estimate?

*How much of this have you already paid or plan on paying during or after treatment?

*It is rare that PBRC has enough funds to cover the full amount needed in most cases. What amount will you contribute?

*After your contributions and other donations pledged at this point, what is the balance due or what is the anticipated balance due?

*Based on advice from the vet, how urgent is it for the dog to receive the care it needs?

*Do you already have an appointment scheduled for this veterinary care?

*If you have answered "yes" please list when:-

-- mm/dd/yy

*What is the prognosis for your dog after receiving care for this diagnosis?

*Does your dog have any other medical condition?

*If you have answered "yes" please specify:-

*Have you applied to any other sources for the help you need, i.e. Care Credit?

*If you have contacted other sources please use the space below to tell us 1) who you have contacted, 2) phone number and, 3) results:

*How many other pets do you have?

*Additional comments you'd like to share with the fund committee members?

Thank you for taking the time to answer our questions, a volunteer will reply back or call you shortly if we don't have enough information. All request unless deemed an emergency, have a 3 day vote period, once all questions have been answered.

PBRC Fund Committee