Company First Name * Last Name * Address * Address Line 2 City * Postal Code * Province * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Phone * Email * Secondary Contact # Is this for your pet or a friend/family members? * Friend/Family members pet My pet Breed (if know) Mom cats name?: Approximate age of mom cat/dog * Are there any health concerns with the mom cat/dog or kittens? If yes, please describe Is your pet showing any symptoms: vomit, rash, diarrhea? If yes, please describe * Do you currently have a vet? If yes, please list the name and clinic below: * How many kittens/puppies do you have? * Still pregnant (not yet given birth) 1 2 3 4 5 6 If known, please tell us the date the kittens/puppies were born. If unsure, please list their approximate age. * Any health challenges with the kittens/puppies? If yes, please describe. * Are you currently on EI, social assistance or disability or are you a full time student or senior on a fixed income? * Yes No Note: Even if you answer 'No' to this question, you will still qualify. Please fill out the rest of the form. Number of adults in your household. (Do not include roommates) * Number of children in your household. * What is your total yearly household income? * Any other assistance needed? Any other questions?
