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Humane Society of Montgomery County Application for Spay/Neuter Assistance _________________________________________________________________________________
Name:____________________________________________________________________________________ Address:__________________________________________________________________________________ Home Phone:____________________ Cell Phone:___________________ Work Phone:__________________
How do you prefer to be contacted? Home Cell Work
To help us assist you in the most efficient manner, please read carefully and complete all portions of this application. Incomplete applications will not be processed and therefore we will not be able to assist you. It is important that you list all the dogs and cats currently in your care as well as all animals needing to be spayed or neutered. THE HSMC WILL ONLY KEEP YOUR APPLICATION ACTIVE FOR 30 DAYS AFTER WE CONTACT YOU.
LIST ALL DOGS AND CATS WHO CURRENTLY RESIDE IN YOUR HOME ON OR YOUR PROPERTY. (ANY ANIMAL YOU OWN OR ARE CURRENTLY FEEDING MUST BE LISTED ON THIS APPLICATION) DOGS-Please list all dogs in your care below (if you need more space, use the back of this form)
CATS-Please list all cats in your care below (if you need more space, use the back of this form)
PLEASE LIST ALL ANIMALS IN YOUR CARE WHO NEED TO BE SPAYED/NEUTERED BELOW
(if you need more space, please use the back of this form) *If the cat(s) you have are feral/wild (you cannot touch them or pick them up): Will you need a trap to catch them? YES NO Do you have your own trap? YES NO
Have you checked with local vet clinics for a price quote on this surgery? YES Clinic________________ Price $_________________ NO How much can you afford to pay? $_______________________
Have you had an animal spayed or neutered through the HSMC before? YES NO If yes, please explain ____________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Please check all that apply to you:
____ Own home ______ Social Security/Disability _____Unemployment
_____Rent home ______Food stamps ______Student
Please indicate your monthly income$________________
This information is necessary for the HSMC to determine which type of assistance is most beneficial to you.
Where did you hear about our program: (please check all that apply)
____friend/relative ____ vet clinic/hospital ____newspaper/TV ____Website
____Flyer ____Shelter/Rescue ___Other
I certify that all information given on this application is true and correct to the best of my knowledge. I have omitted nothing that would make this application false or misleading.
I understand that the HSMC will only provide assistance for the spay or neuter surgery; any other costs incurred (vaccines, pain medications, tests, etc.) will be my responsibility unless approved prior to surgery.
The information given on this application will never be released to any other person or organization. The information given on this application used to determine assistance needed to refine our program and assist the animals of Montgomery County.
Signature__________________________________________ Date_______________(online application)
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