K9 SNAP K9 SNAP Please complete this form to be considered for our Canine SNAP Program. If you have any questions, please contact Taylor at (406) 388-9399 ext. 204. Name * Name First First Last Last Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone * Email * Who is your veterinarian? * How did you hear about SNAP? * Have you used our SNAP Program before? * Yes No Do you have other pets? * Yes No If so, how many? What kind? * Are they spayed/neutered? * Information about your dog(s). If you are applying for more than one dog, please expand this section to add additional dogs. Dog's Name Sex * Male Female If female, how many litters? * Age? * Approximate weight? * How did you obtain this dog? * How long have you owned this dog? * Any known medical conditions? * Does your dog need to be muzzled for the vet? * Yes No Has not been to a vet Has your dog bitten anyone in the past 10 days? * Yes No Do you have additional dog(s) to add to the application? * Yes No Information about your dog(s). Dog's Name Sex Male Female If female, how many litters? Age? Weight? How did you obtain this dog? How long have you owned this dog? Any known medical conditions? Does your dog need to be muzzled for the vet? Yes No Has not been to a vet Has your dog bitten anyone in the past 10 days? Yes No Has not been to a vet Do you still have additional dogs to add to this application? Yes No Information about your dog(s). Dog's Name Sex Male Female If female, how many litters? Age? Weight? How did you obtain this dog? How long have you owned this dog? Any known medical conditions? Does your dog need to be muzzled for the vet? Yes No Has not been to a vet Has your dog bitten anyone in the past 10 days? Yes No Has not been to a vet Information about your need for assistance. Do you participate in any of the following government assistance programs? (Check all that apply) * Healthy MT Kids Plan MT Head Start MT LIEAP MT Medicaid MT School Breakfast & Lunch Program WIC MT Summer Food Service Food Stamps Unemployment Insurance Section 8 Social Security (Main Income) Unemployment None Please give us any other information that would help clarify your need for financial assistance. * I understand that the SNAP Program is for low income pet owners only or people who are having financial difficulties right now. I certify that the information on this application is accurate. * I understand *Once we review your application and determine if you are eligible for our SNAP/TNR Program we will reach out for scheduling. Please be aware that our clinic is typically booked out for a few weeks so an immediate appointment may not be possible.* Captcha Date * Submit If you are human, leave this field blank.
