<p> Vet Pet Coalition Applicants</p><p>The Veteran’s Pet Community Coalition provides quality trained companion animals that enrich veteran’s lives and promote good health through companionship.</p><p>Branch of service: ___ Army ___ Navy ___ Marine Corps ___ Air Force ___ Coast Guard ___ National Guard Status: ___Active ___Veteran ___Retired ___Reservist</p><p>REQUIREMENTS: Discharge from the military with an honorable, under honorable condition or general under honorable condition. Please provide a copy of you DD214 (Assistance with obtaining a DD214 can be found at your local County Veterans Service Office).</p><p>Please state any disabilities you may have, Service Connected and Non-service Connected. This will assist the trainer in matching up the right canine and training type) ______Which type of animal are you applying for:  Dog  Cat  Other The Fox Valley Humane Association is dedicated to matching your new companion animal to fit into you and your family’s life style. Please tell us about what you are looking for in a companion animal? What size dog? What breed? ______</p><p>YOUR INFORMATION:</p><p>Last Name: ______M.I. _____ First Name: ______Spouse or Roommate’s Name: ______Driver’s License Number: ______Address: ______City: ______State: ______Zip Code: ______Area Code/Primary Phone: ______Area Code/Secondary Phone: ______E-mail (needed to register for Shelter Care Pet Insurance): ______Have you ever adopted from the FVHA before?  NO  YES If yes, when & what? ______When you are not home, where will your pet be kept: ______How long are you gone during day? Self ______Spouse/Roommate ______How many Adults live in your home? _____ Children? _____ Children’s ages:______Do you live in a  House  Apartment  Condo  Dorm  Mobile Home Do you own the property at the address above?  YES  NO If you rent, please list the landlord’s name & phone number: ______Please provide the name & phone number of any veterinarian that you have used in the past 5 years. Veterinary Clinic: ______Area Code/Phone #: ______Name that is listed on the account with the Veterinary Clinic: ______Which animal(s) were seen there? ______</p><p>Current Pet Information – Please list current and other pets you have owned in the past five (5) years. Breed of Animal Pet’s Name M/F Spay/Neuter Kept Where? Age Still Have? Why not?</p><p>______M F  Yes  No IN OUT ______</p><p>______M F  Yes  No IN OUT ______</p><p>Are all of your animals up-to-date on rabies & distemper vaccinations?  Yes  No  Unsure</p><p>Please provide the name & phone number of a person who we may contact in the event that you are unavailable. Contact Name: ______Area Code/Phone #: ______</p><p>Please provide two NON-RELATED references that you have known for more than 2 years. Provide us with their names & phone numbers where they can be reached between the hours of 9:00 a.m. to 5:00 p.m.:</p><p>Name: ______Area Code/Phone #: ______</p><p>Name: ______Area Code/Phone #: ______</p><p>The Vet Pet Coalition requires that the veteran recipient volunteers for the Fox Valley Humane Association (Or the closest shelter if out of the Fox Valley Area) at least 40 hours. Will you be able to meet this requirement? If not, why not? ______FVHA Staff Only FVHA Records______</p><p>Veterinary Reference______</p><p>Reference______</p><p>Trainer comments______</p><p>Notes______</p>