Talbot County Humane Society

Talbot Humane

Spay/Neuter Program Application for Financial Assistance

P.O. Box 1143, Easton,Maryland21601

PH(410) 822-0107 FX(410) 822-7619

In order to be eligible for our program, your pet must have current rabies and distemper vaccination.

Talbot Humane, Inc. reserves the right to have the surgery performed by the veterinarian of our choice.

Each veterinary hospital reserves the right to require specific tests or vaccinations prior surgery. Please check with your veterinarian for specific requirements.

Applicant’s Information:

1. Name ______

2. Physical Address______

3. Home Phone: ______Work Phone:______

4. Annual Household income: ( ) $10,000 or lessCO PAY $25.00

( ) $10,001 - $20,800

( ) $20,801- $40,000

( ) over $40,000

You must provide proof of income. All financial information will be held in confidence.

5. Are you: ( ) married ( ) single? Number of dependents: ______

Animal information:

1. Is this application for: ( )dog ( ) cat? Pet’s name______Color______

2. Is it ( ) male ( ) female? Is your female possibly pregnant? ______In heat? ______

Any extra costs incurred because your pet may be pregnant or in heat will be your responsibility. There may be additional costs incurred due to other medical problems that will also be your responsibility.

3. Pet’s age: ______Breed: ______

4. Is it: ( )small(5-20 lbs.) ( )Medium(25-50lbs) ( )Large (over 50lbs.)

5. Please circle one of the participating veterinarians: Pet Health Clinic

Midshore Veterinary Clinicor All Pets Veterinary Services

6. Check the following vaccinations your pet has received in the past year.

( ) distemper( ) rabiesNote: proof must be provided at time of surgery.

7. What other pets do you have?

Pets name______( )dog ( )catSpayed or neutered? ( )yes ( )no

I agree the above information is correct and that the Talbot Humane, Inc. isreleased from all liability associated with my pet’s surgery.

Date______Signature______

OFFICE USE ONLY: RECEIVED:FAXED: CALLED:

(Ed. 2/13)