Pit Bull Rescue Central

Name of organization:
Organization contact person (if different than the requester):
Type of organization:
If other, please explain:
Is the shelter a not-for-profit 501(c)3 organization?	Yes No
Shelter mailing address:
Shelter mailing address (line 2):
City:
State or Province:
Zip/Postal Code:
Email address for the organization:
Website URL for the organization:
Day phone contact number:
Evening phone contact number:
Your name (we will need one person as the contact):
Your phone numbers (if different from organization contact numbers):	Day Eve
Your email (if different from organization email, please use an email address you are able to check often):

General information related to the case: Please tell us about your financial situation and why you are asking for help. The more details you provide, the easier it will be to process your request. If we don't have enough information, we will contact you. This will delay the process and could impact when the decision is made for your case.
What is your dog's name?
What is your dog's age?
What is your dog's gender?	Male Female
Is your dog spayed/neutered?	Yes No
What is the breed of your dog?
Where did you get the dog from?
Has the dog been temperament tested? If yes, did the dog pass?	Yes No Yes No
Is the dog listed for adoption? If yes, where (please include link if applicable)?
Is your dog current on vaccines, including heartworm preventive medication and rabies?	Yes No
What is the diagnosis of the medical problem? Please be specific:
Is the shelter able to keep the dog during treatment and until a suitable home is found for him/her?
Name and address of vet or animal hospital from which estimate was received
Contact person for your dog's case, phone and/or fax number:
Does the vet/contact person have email and/or website?	Yes No Don't know
If yes, please list the details:

What is the cost quoted on the vet's estimate?
How much of this have you already paid or plan on paying during or after treatment?
It is rare that PBRC has enough funds to cover the full amount needed in most cases. What amount will you contribute?
After your contributions and other donations pledged at this point, what is the balance due or what is the anticipated balance due?
Based on advice from the vet, how urgent is it for the dog to receive the care it needs?
Do you already have an appointment scheduled for this veterinary care?	Yes No
If yes, please list when (mm/dd/yy):
What is the prognosis for your dog after receiving care for this diagnosis?
Does your dog have any other medical condition? If yes, please explain:
Have you applied to any other sources for the help you need, i.e. Care Credit?	Yes No
If you have contacted other sources please tell us 1) who you have contacted, 2) their phone number, and 3) results:
How many other pets do you have?
Additional comments you'd like to share with the Fund Committee members?
How did you hear about PBRC Funding?

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