Reorder Form - Food Assistance

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This form should be used by existing members only. If you are not an existing pet food assistance member and need pet food assistance, please fill out our food assistance program application.

PLEASE NOTE: OUR PET FOOD PANTRY PICK DAYS ARE ON THE 2ND AND 4TH SATURDAYS OF THE MONTH BETWEEN 10am - 12pm.

We are a volunteer based program. While we understand that things happen, life happens and we cannot always meet our obligations, we ask that you give us as much notice as possible if you're unable to pick up on your assigned day. Failure to pick up on your assigned day THREE times without a call / text to (216) 307-7814 or email us at cpocfoodassistprogram@gmail.com will disqualify you from our program.

HAVE YOU HAD ANY CHANGES WITHIN YOUR HOUSEHOLD i.e. NEW ADDRESS, NEW PHONE, NEW e-MAIL OR A NEW PET(S)? IF SO, SKIP THIS FORM AND FILL OUT A NEW PET FOOD ASSISTANCE APPLICATION VIA THIS LINK: PET FOOD APPLICATION: *

YES

Required

Member's Name *

Member's Address: *

Member's e-Mail address: *

Member's Phone # *

Can we text this #? *

YES

Name of Pet #1 *

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

WAS THIS ANIMAL VACCINATED WITHIN THE LAST YEAR? IF SO, WE'LL REQUEST A COPY OF THOSE VACCINE RECORDS.
*

YES

Required

Name of Pet #2

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

WAS THIS ANIMAL VACCINATED WITHIN THE LAST YEAR? IF SO, WE'LL REQUEST A COPY OF THOSE VACCINE RECORDS.

YES

Option 1

Clear selection

Name of Pet #3

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

WAS THIS ANIMAL VACCINATED WITHIN THE LAST YEAR? IF SO, WE'LL REQUEST A COPY OF THOSE VACCINE RECORDS.

YES

Name of Pet #4

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

WAS THIS ANIMAL VACCINATED WITHIN THE LAST YEAR? IF SO, WE'LL REQUEST A COPY OF THOSE VACCINE RECORDS.

YES

Name of Pet #5

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

Name of Pet #6

CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply: *

Yes, my pet needs their vaccinations. (Distempter and Bordetella)

Yes, my cat needs a microchip.

Yes, my dog needs a microchip.

Yes, my dog needs Heartworm tested.

Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)

No, my pet does not need these services. I do not need more information.

Required

Have you added a new pet to your household? If so, tell us it's name, type of animal, age, weight, color, etc. If no use N/A: *

Do any of your pets require a special diet or on a medicated food? If no use N/A: *

What does pet need? *

Cat Food

Kitten Food

Does your cat/kitten eat canned food?

Dog Food

Puppy Food

Does you dog/puppy eat canned food?

Litter (If available)

Required

Which Saturday do you prefer to pick up this month? *

The 2nd Saturday

The 4th Saturday

Do you or your pet need anything? Any additional information you wish to share? If no use N/A: *

Submit

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