Pooch Park at Pullman
Whitman County Humane Society
APPLICATION
Page 2 of 2 – updated 01/25/17
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Page 2 of 2 – updated 01/25/17
Please note that all applications processed at the shelter will incur a $5 administrative fee EXCEPT DAILY PASSES. Applications are accepted at the shelter from 1-6 PM on open days. Instead, you may mail this completed application to PO Box 453, Pullman, WA 99163 with payment by check.
Please circle one: New / Renewal Voucher Number ______
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Page 2 of 2 – updated 01/25/17
If submitted at shelter, prices including administrative fees are:
☐ Annual $70 (card given at shelter) ☐ Trimester $35 (card given at shelter)
☐ Daily $5 ☐ 2nd card for household (max. 2/household) $10
Total: $______
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If submitted by mail, prices are:
☐ Annual $65 (card will be mailed) ☐ Trimester $30 (card will be mailed)
☐ 2nd card for household (max 2/household) $10 (will be mailed)
☐ I would like to pick up my card(s) at the shelter $5
Total: $______
Owner’s Name(s):
Email Address:
Mailing Address:
City: State: Zip:
Phone number: ( ) ______Work/Cell Number: ( )
Number of Dogs in Household for which you are applying (Please circle) 1 2
All dogs must be spayed or neutered before they are 14 months old
Dog No. 1 information
Dog’s Name: ______Gender: ______
Dog’s Breed and Color/Description:
Age/DOB: Date of Spay/Neuter:
Vaccination Information/Record Dog No. 1
A copy of your dog’s rabies vaccination or titer record for each dog in which you are making an application is required. (List date(s) of record(s))
Rabies or Titer Expiration Date:
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Dog No. 2 information
Dog’s Name: ______Gender: ______
Dog’s Breed and Color/Description:
Age/DOB: Date of Spay/Neuter:
Vaccination Information/Record Dog No. 2
A copy of your dog’s rabies vaccination or titer record for each dog in which you are making an application is required. (List date(s) of record(s))
Rabies or Titer Expiration Date:
By signing below, I certify that the information I have given is true and that any misrepresentation of facts by me, may result in my removal from the Whitman County Humane Society, Inc. (WCHS) dog park, Pooch Park at Pullman, and/or losing the future privilege of using Pooch Park.
I further certify that before using Pooch Park I will promptly or within a reasonable time notify WCHS in writing in the event any of the above information has changed. I certify that I will timely provide WCHS with continuing proof/records of each dog’s vaccinations.
Dated this _____ day of ______, 20____.
For official use onlyPayment type
Card number
______
Owner
Page 2 of 2 – updated 01/25/17