PAP Application Form - A family/friend of someone experiencing FDV 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. Address 4. Address 4. Address 4. Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country 4. Address 5. Preferred contact method – please select one * Phone Email SMS 6. Relationship to pet owner (e.g. friend, sibling, parent) * 7. Pet owner's name (the person experiencing FDV) * 8. Can we contact the pet owner directly? * Yes No direct contact requested 9. If yes, please select the preferred contact method Phone Email Phone Email 10. I confirm that the pet owner is experiencing family and domestic violence and has requested or agreed to this support application * Yes No 11. What is the pet's name? * 12. What species is the pet? * Dog Cat OtherOther 13. What sex is the pet? * Male Female 14. What is the age of the pet? * 15. What breed is the pet? 16. Is the pet microchipped? * Yes No 17. Is the pet sterilised? * Yes No 18. What assistance does your pet require? * Pet food Parasite treatment Pet supplies (beds, leads, collars, etc) Microchipping Sterilisation Vaccinations Veterinary consultation 19. If requires veterinary care, please provide details of the care needed. For example, has the pet been injured, do they require dental treatment, or are they currently unwell? 20. Have you already sought veterinary care? * Yes No 21. If yes, please provide details of the diagnosis and treatment plan 22. Do you give permission for RSPCA WA to discuss this application with your nominated vet clinic? * Yes No 23. 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 24. I confirm that the information provided is true and correct * Yes No Submit
