Please print this page, fill out, and mail with a copy of your driver’s license or Michigan I.D. and a doctor's statement of your disability to:

Pet Support Services, PO Box 18041, Lansing MI 48901

 

Name:

Day Phone:

Address:

Email Address:

City/State/Zip:

 

Emergency Contact:

Phone:

Are you 65 years of age or over?     [   ] Yes    [   ] No

Are you 18 years of age or over?    [   ] Yes   [   ] No

Do you have dependants living with you?  

[   ] Yes   [   ] No    If yes please list:

 

Do you own [  ]  or rent [  ]  your home?

Are you able to drive?      [   ] Yes   [   ] No

Describe your medical or physical condition:

                                                                                                                                                                                                                                                                                                                                                                                                                          

How do these affect your day-to-day living?                                                                              

                                                                                                                                                                                                                                                                                                    

Do your limitation affect your ability to care for your pets?

[   ] Yes    [   ] No   If yes please explain:

                                                                                                                                                                                                                                                                                                                                                                                   

How long have you had pets?

Are your pets up to date on their shots? [   ] Yes    [   ] No

Are your pets spayed or neutered?   [   ] Yes    [   ] No

How much time does your pet spend outdoors?

 

Pet Information

Attach additional paper to describe additional pets. Note: pets are not eligible if classified as wild by DNR or wolf-hybrids.

Pet Name:

Breed:

Age:

Sex:

Color:

Medical Issues:

 

Describe the bond between you and your pet and how

the pet adds to your life:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Financial Summary

Include: Wages, Assistance from Department of Human Services (food stamps etc.), Social Security, SSI, Pension,

Veteran Benefits, Child Support, Energy Assistance, Lansing Housing Commission or MSHDA. Please provide proof of income.

 

Source:

Amount:

 

Source:

Amount:

 

Source:

Amount:

 

Signature:

Date:

Client Application

To contact us:

Phone: 517-267-9299

 

Email:

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