DWC Funding Application Agreement
This is Dachshund World Charities Electronic Funding Application Request.
Email address *
Name *
First and last name
Your answer
Phone number *
Your answer
Other Phone
Your answer
Street Address *
Your answer
City/Town *
Your answer
State/Province *
Your answer
Zip/Postal Code *
Your answer
Country *
Co-Applicant *
Co-Applicant Info
If you answered YES to Co-Applicant, please provide the details. This could be your pet's co-owner, spouse, partner, family member, anyone else who might take responsibility for the health and well-being of your pet. A Co-Applicant should also apply for Care Credit.
Your answer
Did your Co-Applicant apply for Care Credit? *
Active Fundraisers? *
Active Fundraisers means you currently are asking for help by means of other Crowd Funding sites (ex: Go Fund Me, You Caring, etc...)
Yes to Active Fundraisers
If you answered YES to active fundraisers, please provide the details below, such as a GoFundMe URL.
Your answer
Name of your pet *
Your answer
Pet's gender *
Type of Pet *
Pet Breed *
Pet Age *
If you don't know, a best guess is fine.
Your answer
Description of Diagnosis, Medical Treatment, Symptoms or Injury: *
Your answer
**Estimated Cost of Treatment *
You can also send us your vet/clinic estimate, if you have one by emailing or faxing DWC.
Your answer
** All applications must be submitted answering the “CareCredit” questions. Later, you will be asked for the approval or denial letter showing the amount approved or the denial letter/email. Canadians can apply www.petcard.ca
Have you applied for Care Credit? *
If you answered YES to Care Credit, were you denied?
If you were approved for Care Credit, how much were you approved for?
Your answer
Name of your Veterinary or Clinic *
Your answer
Veterinary/Clinic Address *
Please provide the full address of your Vet or Clinic
Your answer
Veterinary/Clinic Phone Number *
Your answer
Veterinary/Clinic Fax Number
Please provide your vet's fax number, if you know it. It helps us out!
Your answer
Veterinary/Clinic Website Address (URL)
Your answer
I attest that the information I have provided to Dachshund World Charities is accurate and complete. I give my consent for the above mentioned medical care. I understand that Dachshund World Charities assumes no liability and makes no assurances as to the appropriateness, quality or outcome of any medical diagnosis, treatment, products or services.
I consent to allow Dachshund World Charities the use of any pictures and description of medical care for the purposes of promotion and fundraising.
EIN: 46-5080303 Dachshund World Charities is an IRS approved 501 (C) (3) non-profit charity.
Email: help@dwcharities.com Fax: (905) 784-1122
Comments
If you have other information that you would like us to know, you can enter it here
Your answer
Please enter the date of your application *
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Electronic Signature *
By entering your name, you are signing this funding request application. Please type your first and last name.
Your answer
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