Application for Funding
(To be completed only after reading our Guidelines for Funding)

Please provide the following information to the best of your ability. If a question does not apply to your situation or to this specific rescue dog, simply put "NA" (for not applicable) in the space provided.

Date: _____________________   Is this an emergency situation? ___________

Individual Applying for Funds:
  Your Name: ______________________________        SOS-SRF logo
  Your Address: ______________________________
    ______________________________
  Your Phone Number(s): ______________________________
Your Email Address: ______________________________

Your Rescue Organization (if not applicable, skip to Name of Dog):
  Name of Organization: ____________________________________________
  Your Position in Organization: ____________________________________________
  Alternate Contact in Organization: ____________________________________________
  Contact"s Address: ____________________________________________
Contact"s Phone Number: ____________________________________________
Contact"s Position ____________________________________________
  Contact"s Email Address: ____________________________________________

Name of Dog _________________________________________________

Siberian Husky    or Siberian Husky Mix    (Please provide picture if possible)

Age ______    Sex ________    Coat and Eye color _________________________________

Is dog spayed/neutered? __________

If not, why not? ____________________________________________________________________________


How did you obtain the dog? _________________________________________________________________


FOR MEDICAL FUNDING:

Your veterinarian or veterinarian providing services for which you are requesting funds:
  Name: ______________________________  
  Address: ______________________________
    ______________________________
  Phone Number: ______________________________


Please describe below, in your own words, why you are applying for funds for this dog:

What is the treatment for which you are requesting funds?



What is or was the medical condition necessitating this treatment or procedure?



What is the full cost of the treatment and why are you in need of outside funding? (Please include fully itemized statements or written quotes on the veterinarian's letterhead for the treatment.)



What is your veterinarian's prognosis for the dog upon completion of the treatment? (If possible, include a signed statement from your veterinarian on letterhead paper.)



What are your long-term plans for this dog?



To whom should any funds we grant be remitted?



Please understand that the following questions are intended to assure the best use of the limited funds available to the Siberian Husky rescue effort without compromising quality of treatment. We encourage second opinions and requesting of discounts for rescue.

Have you sought a second opinion on the necessity or the pricing of the treatment? What was the result?



Have you sought any other sources of funding for this treatment? If so, from whom and what was the result?



Have you inquired whether your veterinarian offers a discount for rescue dogs and if so, does your cost above reflect that discount?



Have you inquired of any other veterinarians in your area about rescue discounts? _____
If another veterinarian does offer a discount and you are not taking advantage of that, please describe why you prefer to remain with your veterinarian.



Release of information: I authorize this named veterinarian or his/her representatives to release any and all information to the SOS-SRF about the medical condition and treatment of the dog that I have listed on this funding application. SOS-SRF will use this information solely to verify the validity of my application for funding from SOS-SRF. Please initial _________

By signing and dating below, I (we) acknowledge that I (we) have read the guidelines published on the SOS-SRF web site and certify that this application falls under those guidelines, including the requirement of submission within 45 days of incurring the last expense. I (we) agree that if the application is found not to comply with those guidelines or if all supplemental materials are not submitted within 10 days of receipt of this application, it will not be considered further by the SOS-SRF board.

Name______________________________________________________ Date ______________________

Please check the following list to be sure you have included the items we need to process your application efficiently. It is your responsibility to ensure that all supporting documentation is received within 10 business days of the initial application or it will not be considered.
You may submit this application to Robert Baker, Rescue Grants Coordinator - SOS-SRF, either through email at rpeabaker@comcast.net, by FAX to (908) 369-3809, or by snail mail to

Robert Baker
207 Saxson Street
Hillsborough, NJ 08844


Last modified: 2008-07-07