Application - Wichita Animal Action League

Vet Assistance Application

"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Applicant's Name*

First Last

Social Security Number*

Applicant's Date Of Birth*

Applicant's Cell Number*

Applicant's Home Phone

Applicant's Address*

Street Address Address Line 2 City State ZIP Code

Rent/Own Home*

Rent

Own

Years Since*

Mailing Address (if different than above)

Street Address City State ZIP Code

If residing at current address less than two years, former addresses:

Street Address Address Line 2 City State ZIP Code

Applicant Driver's License #*

State Of Registered License*

State

Upload Copy of Driver's License*

Max. file size: 20 MB.

Marital Status*

Applicant's Email:*

Employment/Income Information

Name Of Employer*

Employer's Address*

Street Address City State ZIP Code

Employer's Phone*

Position/type of business*

Employment Type*

Full-time

Part-time

Self-Employed

Years on the job*

Monthly Gross Income*

Other Income Type

Other Income Monthly Gross Income

Other Income Type

Other Income Monthly Gross Income

Veterinary Information

Name of Vet*

Clinic*

Phone Number*

Address*

Street Address Address Line 2 City State ZIP Code

Description of Issue with your Pet*

Date of Consultation with vet for this issue ?*

Estimate cost of necessary vet services*

Upload a photo or PDF of the estimate or invoice

Max. file size: 20 MB.

Upload your Care Credit*

Max. file size: 20 MB.

Upload your Scratch Pay*

Max. file size: 20 MB.

Recommendation from vet*

How much are you requesting from WAAL ?*

If your request is approved, you may be required to repay all or part of the assistance funds.

What amount are you willing and able to pay per month toward this debt?*

Signature*

Date*