PAP Application Form - Experiencing homelessness Please complete the form below so we can understand your needs and suitability for the Pet Assistance Program. 1. Name * 1. Name First Name First Name Last Name Last Name 2. Email * 3. Phone * 4. Preferred contact method – please select one * Phone Email SMS 5. Referral person * 6. Referral contact details * 7. Do you give permission for RSPCA WA to discuss this application with your referral person? Yes No 8. What is your pet's name? * 9. What species is your pet? * Dog Cat OtherOther 10. What sex is your pet? * Male Female 11. What is the age of your pet? * 12. What breed is your pet? 13. Is your pet microchipped? * Yes No 14. Is your pet sterilised? * Yes No 15. What assistance does your pet require? * Pet food Parasite treatment Pet supplies (beds, leads, collars, etc) Microchipping Sterilisation Vaccinations Veterinary consultation 16. If your pet requires veterinary care, please provide details of the care needed. For example, has your pet been injured, do they require dental treatment, or are they currently unwell? 17. Have you already sought veterinary care? * Yes No 18. If yes, please provide details of the diagnosis and treatment plan 19. Which veterinary clinic did your pet attend, and what are the contact details? 20. Do you give permission for RSPCA WA to discuss this application with your nominated vet clinic? * Yes No 21. Please upload proof of identification (for example, a WA driver's licence, passport, or WA Proof of Age card) * Drop a file here or click to upload Choose File Maximum file size: 10MB 22. I confirm that the information provided is true and correct * Yes No Submit If you are human, leave this field blank.
