Application for Low Cost Spay/Neuter Fentress County Only
Please print
Name Phone #
Last First Middle Must Provide Phone #
Mailing Address City Zip
Social Security # Birth date
Employer Job Title
Employers Address Phone
Salary / Weekly Hourly Hours per Week
Spouse's Name Social Security # Birth date
Employer Job Title
Employers Address Phone
Salary / Weekly Hourly Hours per Week
Total number in Household_______
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Name of dependent (s) living with you |
Age |
School/Vocation |
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Applicant must present proof of income. Please attach a copy of one or more of the following:
(Application will not be processed without attached proof of income.)
1. Current pay check stub (both if applicable) 2. EBT Card / Food Stamps 3. Public Housing
4. Proof of Social Security Benefits 5. Medicaid / WIC. 6. Copy of previous year’s income tax return (s)
PET INFORMATION
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Pets Name |
Dog |
Dog Breed |
Cat |
Weight |
Age |
Male |
Female |
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Client Declaration and Release: I certify that the above information is true and correct. I hereby give permission to contact my employer about my income and understand that the information may be investigated in certain cases where further verification is needed.
Applicant's signature Date
For additional information call 879-6806
Complete and mail to: Best Friends Sanctuary, P.O. Box 1038 Jamestown, TN 38556
For office use only:
Date notified Phone Letter Notified by:
Spay / Neuter Date Response /Notes
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Vet- Check one - Dogwood Animal Hospital Upchurch Animal Hospital