Nebraska Animal Rescue

NEBRASKA ANIMAL RESCUE

CHOWSER’S PROMISE

APPLICATION FOR ASSISTANCE

You are required to have been actively rescuing for a minimum of one (1) year and been a Nebraska Animal Rescue list member in good standing for at least six (6) months.

Please fill out all information requested below and return to . An incomplete application will only lead to a delay in assistance. .

If this is an emergency situation requiring an immediate response, please contact Dawn at 308-238-1420 and she will return your call as soon as possible otherwise all requests will be acknowledged within 24 hours.

A picture of the rescued animal must be sent to Assistance is available for rescued animals, not personal pets.

Date:

Rescue Group/Shelter Name:

Nebraska Dept of Agriculture Identification #:

If 501(c)3 registered, list your Federal or State EIN #

:

Contact Name:

Address:

City/State/Zip Code:

Telephone:

Cell Phone:

Email:

ANIMAL INFORMATION

Type of Animal:

Breed of Animal:

Name of Animal:

Sex:

Date Animal was rescued:

Approximate age:

Has the animal been spayed or neutered yet?

MEDICAL ASSISTANCE

Provide a full description of the rescued animal’s illness, injury or vetting needed:

Animal’s current location:

Name, address and phone number of treating veterinarian:

Veterinarian EIN Number if being paid direct:

Describe the animal’s medical diagnosis/prognosis:

Describe the recommended course of treatment:

Please specify the amount you are requesting from Chowser’s Promise:

SHELTER FEE ASSISTANCE

If your request is for reimbursement of shelter fees please give the name/address/phone/Federal Tax ID number of the shelter and the amount of the fees:

MISCELLANEOUS EXPENSES

It is our hope to also be able to assist with food, grooming, bedding, etc. If you have a need of that type at this time please fill out the following:

Service/Product needed:

Quantity:

Cost:

The original invoice/statement/receipt being submitted to Chowser’s Promise must be mailed to Dawn Lynch at 1806 4th Av, Kearney, NE 68845 at the time of the request or within 7 days along with a copy of this application signed, by hand, by the rescue representative. Failure to comply will affect future aid.

I hereby state that the information given in this application is true and understand that I must provide the Board of Directors with the best information possible. I also understand that I am not required to reimburse Chowser’s Promise for their donation.

______by______

Rescue Organization Name Organization Representative