SPAY AND NEUTER APPLICATION

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SPEUTER VOUCHER PROGRAM APPLICATION

In an effort to combat the problem of pet overpopulation and to promote healthy pet-care, B.A.A.C. has partnered with a few area veterinary hospitals and clinics in Connecticut to provide spay and neuter services. The Clinic will provide spay or neuter services and B.A.A.C. will cover the balance depending on the needs of the program participant.

SPEUTER is intended to assist low-income pet owners, senior citizens or independent rescuers afford the cost of spaying or neutering their dog or cat. Our SPEUTER program is made possible through generous donations, grants, and the generous time and resources by participating veterinarians who believe in the importance of spaying and neutering as part of a complete pet healthcare program. This program will last as long as the funds are being provided that enable us to make available this very important and valuable service.

In order to apply for assistance, simply fill out this form completely and mail to above address, you will be notified about your eligibility for SPEUTER after your application is received.

You may only apply for your own dog and/or cat. If you have more than one pet that needs to be spayed or neutered, please include that information about the other pets that need assistance.

I certify that I own the pet this application is being submited for.

IMPORTANT

Please fill in all fields. If a field does not apply to you, please type in "N/A" or "0". Applications take 2 weeks to process. Incomplete applications may be denied.

SECTION I: All Fields in this section are required

*First Name:

*Last Name:

Birthday

Address

City

State

Zip Code

Phone

Cell Phone

Would you like to receive periodic updates from Bikers Against Animal Cruelty Inc.

Yes

SECTION II: Employment. Proof of employment may be requested.

Employer

Employer Address:

Job Title

SECTION III: Employment. Proof of income may be requested.

What is the total household income per week?

SECTION IV: please include all details regarding your pet that you are applying for SPEUTER services for.

Pets Name:

Pets Breed:

Species

Dog

Cat

Gender

Male

Female

Weight:

Age:

Color & Markings

How did you acquire this pet?

How long have you had this pet?

Do you bring your pet for regular veterinary check ups?

Yes

If this pet is a female, has she ever had a litter:

Yes

If YES how many?

If so please list the veterinary office name and address:

Please list all vaccinations and most recent dates they were administered

Do you let your pet(s) go out doors unsupervised?

Do you have any other pets, if so please list all other pets?

Are these pets spayed or neutered?

Please list the following information for any other pets that needs spay and four neuter assistance.

(Include NAME / SPECIES / GENDER / COLOR / WEIGHT / AGE / HOW ACQUIRED / HOW LONG YOU'VE HAD THE PET/ NUMBER OF LITTERS IF APPLICABLE): species gender color weight age how acquired how long you've had the pad number of letters if applicable

Aditional information.

How did you hear about the SPEUTER Voucher Program?

By signing this form, I CERTIFY that the personal details provided on this form are true and correct.

Your Signature - use your mouse or finger to sign below.

Type Name:

Date:

Thank you for helping us make a difference!

SPEUTER VOUCHER PROGRAM APPLICATION

Bikers Against Animal Cruelty

P.O. Box 68

North Haven, CT 06473