Personal Information

Your Name

Address

City, State and Zip Code

County BooneClayLincolnLoganKanawhaPutnam

Phone #

Email

How should we send your voucher(s)? E-mailUS Mail

Mailing Address

Mailing Address

City, State and Zip Code

Pet Information

1. Pet's Name

Type of Pet —Please choose an option—dogcat

Sex —Please choose an option—malefemale

Breed

Weight (Required for dogs)

Age

Color/Markings

Where did you get the pet?

2. Pet's Name

Type of Pet —Please choose an option—dogcat

Sex —Please choose an option—malefemale

Breed

Weight (Required for dogs)

Age

Color/Markings

Where did you get the pet?

3. Pet's Name

Type of Pet —Please choose an option—dogcat

Sex —Please choose an option—malefemale

Breed

Weight (Required for dogs)

Age

Color/Markings

Where did you get the pet?

Do you have more than 3 pets needing spayed or neutered? yes

If yes, list additional information here:

Please select one of our participating veterinarians.
The Critter Connection (9 Boise Street, Chapmanville, WV)The Fix 'Em Clinic (102 Dee Drive, Charleston, WV-cats only)Healing Paws Veterinary Center (3847 Teays Valley Road Suite D, Hurricane, WV)Help for Animals (One Humane Way, Barboursville, WV)

Do you have any additional questions or remarks?

Instructions

If this application is approved, you will receive one authorization form for each pet being spayed or neutered. Once you receive the voucher form(s), call the vet to make an appointment. You must present the authorization form(s) to the vet when you take your pet for its appointment.

If you are unable to keep your appointment, you must give at least 24 hours' notice to the vet's office. Failure to do so will result in losing access to this program.

You Must Read and Acknowledge The Statement Below

By typing my name in the line below, I understand all questions on this application must be answered or this application will not be processed. I also certify the accuracy of the information I have provided.

Type your name (in lieu of signature)

Today's Date

Thank you for helping to make your pet a healthier and happier companion, and for helping stop pet over-population. Please call our office at 304.562.0300 if you have any questions.