Application - Wichita Animal Action League

Vet Assistance Application

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: 256 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 ?*
MM slash DD slash YYYY
Estimate cost of necessary vet services*
Upload a photo or PDF of the estimate or invoice
Max. file size: 256 MB.
Upload your Care Credit*
Max. file size: 256 MB.
Upload your Scratch Pay*
Max. file size: 256 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?*
Consent*
I certify that this information is accurate and complete. I will abide by the terms and conditions of the Pet Vet Assistance Program.
Signature*
Date*
MM slash DD slash YYYY

Vet Assistance Application

Employment/Income Information

Veterinary Information

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