** Today's date (mm/dd/yyyy)

** Your first name   ** Last name   

** Email      ** Re-type your email 

** Phone (include area code) ** Cell

** Is your application request for a pet with a rescue group? YES NO
 

** What is your pet's name?   

** What kind of pet (dog, cat etc.)

** What is the treatment your pet needs within the next 5 days to prevent death or euthanasia?       

** Is your pet currently in the hospital? YES  NO

** If your pet is NOT in the hospital were they sent home due to your lack of funds?
YES NO This question does not apply to me

** Has your pet been spayed or neutered? YES  NO

** What treatment has your pet already received for this condition?  Type your answer below:

As a registered charity imom is required to have certain documents on file. 

NOTE - We cannot send you an application until you have faxed all necessary documents to
630-214-8952 

Have the following documents been faxed to IMOM?  If not please do not continue. 

1. A written estimate from your veterinarian for the full cost of treatment needed.  The veterinarian must also advise IMOM whether or not your pet is facing death or euthanasia if not treated within 5 days or less.
   ** Yes, the estimate has been faxed
   ** Date faxed 
   
   If not faxed do not continue. 

2. Have you or your veterinarian faxed the Veterinarians Pet Information Form (VPIF) to IMOM? 
   ** YES NO
    

3. Your proof of income. (Does not apply to rescue groups)
   ** Yes, proof of income has been faxed
   ** Date faxed 
   
   If not faxed do not continue unless the pet is in the care of a rescue group. 

4. Letter of approval or denial from Care Credit. (Does not apply to rescue groups)
   
   You are required by IMOM to apply for Care Credit if your veterinarian accepts Care Credit.
   
   ** Choose from below:
   
   My veterinarian does not accept Care Credit
   I was approved but not for the full amount needed
   I applied for Care Credit and was denied

1. I understand that IMOM cannot offer financial aid for treatment that has already been provided or for treatment that may be provided prior to submission and approval of my application.
    

2. I understand that I should not be submitting this request if all required documents have not been faxed to 630-214-8952

By typing your full name in the space below you acknowledge full understanding of the above two paragraphs.

** Your name