Animal Haus Pet Food Pantry Assistance Application and Agreement
Please answer all questions truthfully, all information given is kept strictly confidential. Any false information may
result in disapproval of the application and assistance will be denied. Return to Animal Haus, P.O. Box 140593,
Denver, CO 80214 or petfood@animalhaus.org.
Date:
How did you hear about us?
Name:
Address:
City:
Zip:
Phone:
County:
Alternate Phone:
Email:
# in Household:
Annual Household Income:
Tell us about your hardship or the public assistance you receive (proof will be required):
Have you received assistance from Animal Haus before?
PETS- Please tell us about your pets.
How many pets are in your household?
Please list ALL pets in your household below.
NAME
TYPE OF
PET/BREED
SEX
SIZE/WEIGHT
SPAYED
OR
NEUTERED
Is your pet(s) on a special diet? If so, tell us more.
Is there any type, brand or flavor of food that your pet(s) will NOT eat?
Do any of your pets have health concerns? If so, tell us more.
Animal Haus Pet Food Pantry Application & Agreement
USUAL
TYPE OF
FOOD
BRAND
REQUESTING
ASSISTANCE?
To be considered for assistance, you are stating that all the following statements to be true by
initialing on the line next to each statement. We may require proof of these statements, if
necessary. Please initial next to each line only if you meet each qualification):
____
____
____
____
____
____
____
____
____
____
____
____
____
1. be the pet's owner
2. be 18 years or older
3. have a picture ID with your current address
4. agree to notify Animal Haus if you move or if the number of pets in your household
changes (it can only decrease as you are not allowed to add pets while receiving pet
food pantry assistance, see #9
5. understand the food provided is donated and may not be your current brand, which may
upset your pet's stomach (it is best to mix the donated food gradually to your current
food)
6. agree NOT to hold Animal Haus Pet Food Pantry, its staff, volunteers and benefactors
legally liable in the unfortunate event your pet(s) become ill or the food upsets the pet's
stomach or pet(s) general health
7. agree NOT to resell the pet food received from Animal Haus Pet Food Pantry
8. agree that you do NOT breed any of your pets for profit or for sport
9. agree that you will NOT add animals for any reason while receiving assistance from
Animal Haus Pet Food Pantry
10. understand that Animal Haus Pet Food Pantry has the right to deny your application.
11. agree to maintain healthy condition/environment living conditions for all pets,
or let someone know if this is not possible
12. agree to give your pet(s) fresh water daily
13. agree not to tether or chain dog 24/7
I certify that I, ___________________________, am the owner of pet(s) _________________________.
I certify that all of the information provided to Animal Haus including my identification, residency and
other information is true and correct. I understand that Animal Haus is not obligated to provide me with
pet food. I understand that Animal Haus is a nonprofit organization that manages from donations. I do
not hold Animal Haus responsible for any outcomes of taking pet food from Animal Haus.
Signed: _____________________________________ Date: Click here to enter text.
Printed Name: ___________________________________ Animal Haus Staff:____________________
OPTIONAL: Would you allow us to take a photo of your pet(s) or you and your pet(s) to be used for advertising
purposes? ______ If yes, by signing above, you agree to relinquish all rights for monetary gain and compensation.
Animal Haus Pet Food Pantry Application & Agreement