Application for Canine/Feline Spay/Neuter Assistance

Application for Canine/Feline Spay/Neuter Assistance

*Please complete all sections of this form
Section 1 - Personal Information
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *

Area Code Phone Number
Cell Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Email *
example@example.com
Name, age, and relationship to applicant of all others residing in same household:
1. *
2.
3.
4.
5.
Section 2 - Current Pets
How many animals do you currently own? *
Number of cats: *
Cat #1 *

Male Female
Cat #1 Age: *
Cat #1 date of last vaccinations *

Month Day Year
Date
Is Cat #1 *

Spayed Neutered Still intact
Provide a brief description of Cat #1 and how it was acquired *
Cat #2

Male Female
Cat #2 age:
Cat #2 date of last vaccinations

Month Day Year
Date
Is Cat #2

Spayed Neutered Still Intact
Brief description of Cat #2 and how it was acquired
Cat #3

Male Female
Cat #3 age
Cat #3 date of last vaccinations

Month Day Year
Date
Is Cat #3

Spayed Neutered Still Intact
Brief description of Cat #3 and how it was acquired
Number of dogs: *
Dog #1 *

Male Female
Dog #1 age *
Dog #1 date of last vaccinations *

Month Day Year
Date
Is Dog #1 *

Spayed Neutered Still Intact
Brief description of Dog #1 and how it was acquired *
Dog #2

Male Female
Dog #2 age
Dog #2 Date of last vaccinations

Month Day Year
Date
Is Dog #2

Spayed Neutered Still Intact
Brief description of Dog #2 and how it was acquired
Dog #3

Male Female
Dog #3 age
Dog #3 Date of last vaccinations

Month Day Year
Date
Is Dog #3

Spayed Neutered Still Intact
Please list all other animals in your household and how they were acquired *
Section 3 - Animal in need of assistance
Is the animal to be neutered a cat or dog? *
Is the animal a male or female? *

Male Female
Name of animal *
Weight (lbs) *
Breed *
Age *
Colour *
If your pet is female, is she currently in heat? *

Yes No N/A my pet is male
Is she currently pregnant? *

Yes No N/A my pet is male
Section 4 - Financial Information
Are you currently employed? *

Yes No
Name of Employer *
If not employed, what is your main source of income? *
What is your total Family Income?

You must provide proof of your total family income status by including a copy of your Notice of Assessment from your most recent Income Tax Statement. This information is essential to qualify for the Spay/Neuter Assistance Program and will be kept confidential. The tax will be destroyed after the application has been processed and the spay/neuter complete. All information provided is considered personal and confidential and will not be shared. Please BLACK OUT your Social Insurance Number (SIN) on the Notice of Assessment as this information is not required
Total Family Income *
Please provide one reference that can be contacted
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
How do you know this person? *
Please explain the reason for applying for spay/neuter assist: *
Section 5
The purpose of the Second Chance Pet Network Spay/Neuter Assistance program is to subsidize the costs associated with examining and performing the Spay/Neuter surgery. If your application is accepted, you are responsible for pre-paying a non-refundable $75.00 fee to Second Chance, before the scheduled veterinary appointment. The client is responsible for delivering their pet to the veterinary clinic prior to surgery and collecting the animal after surgery is complete. If for some reason you cannot make your appointment and you do not cancel 24 hours prior, you will not be refunded your pre-payment.
Do you agree to pay this portion of the spay/neuter? *

Yes No
Do you currently have a vet? *

Yes No
Please provide your Vet's name and clinic *
Section 6
Please use the signature box below to acknowledge that the foregoing information is true and correct to the best of your knowledge and that you have not omitted any information that would make your application false or misleading.

You will be notified once your application has been processed.
Signature *

Clear
For Office Use Only:
Application approved?

Yes No
Signature SCPN official

Clear
Should be Empty:

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