CARA Fund Application Form

Please read all instructions carefully!

Have all information gathered together before you start this application - this form cannot be saved and completed at a later time.
To move between fields, use the "Tab" key.
This application cannot be submitted unless all fields are completed. If you receive an error message it is because one or more fields have not be filled.
Remember this application must be accompanied by a written diagnosis and estimate from your veterinarian. This information can be FAXed or emailed. For additional information, contact:

Email: fjlighthouse@ec.rr.com

Rescue Group Information

Rescue Name: Date:

Rescue Contact Person:

Street Address:

City: State: ZIP Code:

Phone Number: Email Address:

Web page address:

Cocker Spaniel's Information

Name of Cocker Spaniel: Age of Cocker Spaniel:

When was this cocker spaniel brought into your rescue:

Veterinarian Information

Name of veterinarian:

Street Address:

City: State: ZIP Code:

Phone Number: FAX Number:

Diagnosis

Please tell us why you are in need of funds. Remember this diagnosis must be confirmed, in writing, by your vet.

I certify that I am at least 21 years of age and am a legal representative of the rescue submitting this application. I understand that typing my name in the signature box below is considered a legal signature for email purposes.

Signed: Date:

Questions about the form? Please email us for help.