Spay Neuter Assistance Application

Spay Neuter Assistance Application

Please submit an application for each animal.
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Occupation
Is this residence a House, Apt, Condo or Mobile Home?
Spouse's Occupation
How long have you lived at your current address in yrs/mos.?
Household Income
Do You own or rent?
Best Time to Call

Hour Minutes

AM/PM Option
How many adults are in your household?
How many children live in your household?
Are you over 18?
Have you ever applied for a Spay/Neuter Certificate from HSJC?
Pet Name
Species
Breed
Pet Age
Gender
Household Income
Consent to Spay/Neuter Procedure
Agreement to Terms and Conditions
Do you qualify as a senior citizen (65+)?
Do you participate in Government Assistance Programs?
In Which and What Assistance are you receiving?
Do You receive Social Security (SSA)?
How Much
Do You Receive Social Security Disability (SSI)?
How Much
Do You have a Veterinarian?
Veterinarian Name
Veterinarian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Veterinarian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If you have used our program before, please explain when and how many animals you have had altered under our prorgam.
How did you hear about the HSJC Spay/Neuter Assistance Program? (for example, Jackson Herald, Facebook, Twitter, Petfinder, Adopt-a-Pet, Rescue Me, www.HSJC.com, Other)
Certification Statement
By Signing below, I certify that I have read this application in its entirety and understand that my eligibility in the Spay/Neuter Assistance Program will depend primarily on my income level and the availability of HSJC funds. I also certify that all of the information that I have given on this Spay/Neuter Assistance Program Application and in any attached documentation is true and complete and that falsification of any of this information may result in rejection of my application. If my application is accepted, I agree to abide by the policies and procedures outlined in the program description.
Signature
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