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

Applicant's name __________________________________  Date ______________

Street Address  __________________________________  Zip Code ____________

Home Telephone  ________________  Cell # _______________ Work # ____________

Number in your household ______  Number who 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.
 INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

APPLICATIONS CAN BE SENT TO: OLIVE BRANCH ANIMAL RESCUE 
                                                                  PO BOX 183
                                                                  SISTERSVILLE, WV 26175  
FAX: 304-652-3402
                                  

SIGNATURE  ____________________________________  DATE _____________

APPROVED BY ____________________________________  DATE __________________

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