CARROLL COUNTY HUMANE SOCIETY

Application for Funds

Please complete the form below to request financial assistance.

I applied and was declined for Care Credit. *

I am a Carroll County resident *

Name of Applicant *

Care Credit ID# *

Number of Pets *

Occupation *

Email Address *

Primary Phone *

Secondary Phone

Street Address *

City *

State *

Zip *

Pet Name *

Estimated Amount of Funds Needed *

Your Contribution *

Treating Vet *

Procedure / Treatment Description *