Olive Branch Animal Rescue & Refuge, Inc.
                        Family Assistance Program (FAP) Application

Applicant's name __________________________________  Date ______________

Street Address  __________________________________  Zip Code ____________

Home Telephone  ________________  Cell # _______________ Work # ____________

# of People in your household ______  # of People have income _______

       LIST ALL SOURCES OF INCOME FOR EVERYONE IN YOUR HOUSEHOLD

EMPLOYMENT INCOME _______  SOCIAL SECURITY INCOME _______ FOOD STAMPS INCOME  ___________

OTHER INCOME __________  COMMENT ___________________________ 

TOTAL HOUSEHOLD INCOME ____________  OTHER REASON FOR APPLYING _______________________

RABIES ID # _____________________ (REQUIRED BY WV LAW)

ALL PETS IN THE STATE OF WEST VIRGINIA RE REQUIRED BY LAW TO HAVE A RABIES VACCINATION.  ANIMALS THAT ARE BEING SPAYED OR NEUTERED BY THE FAP PROGRAM WILL
RECEIVE A RABIES VACCINATION IF NEEDED AT THE TIME OF SURGERY.  NO SICK OR INJURED PETS CANNOT BE SPAYED OR NEUTERED.  ALL OTHER PROCEDURES ARE THE RESPONSIBILITY OF THE PET OWNERS.
IT IS IMPORTANT TO KNOW THIS APPLICATION CAN ONLY BE APPROVED IF THE APPLICATIONS IS TOTALLY COMPLETE.  ANY INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

APPLICATIONS CAN BE MAILEDTO     OLIVE BRANCH ANIMAL RESCUE   FAX 304 652 3402 
                                                       PO BOX 183
                                                SISTERSVILLE, WV 26175   
                                                

SIGNATURE OF APPLICANT ____________________________________  DATE _____________

APPROVED BY ____________________________________  DATE __________________



The Olive Branch Nancy Dabbs Animal Birth Control (FAP) Program