S/P Coupon Application Form

^{1935 20th Ave SE . Minot,
ND 58701 . 701-839-6116 . FAX 701-838-7622}

Date: ________________ Certificate #: _________________

Spay/Neuter Assistance Application – 2007

The Souris Valley Humane Society is dependent upon donated funds and fund raising events in order to maintain its services. For that reason, we urge those who are financially able, to pay their own veterinary charges for spaying or neutering. If the spaying or neutering of your pet would create a financial hardship, please complete the application form below. The financial assistance may only be available for a limited time. We will be issuing $15.00 coupons for both male and female animals. There will be only one coupon issued per household per month. Names will be drawn weekly to total 12 to 16 per month. The names not chosen one week will go back in for the next week’s drawing.

Applications must be RETURNED TO THE HUMANE SOCIETY*, and are only valid for use at veterinary clinics in the state of North Dakota.

* If you live an extremely long distance form the shelter, Call Darla at 852-6133.

All Information Is Kept Confidential

Please print and supply all of the correct information requested, or application will be voided.

Name ____________________________________Phone: _______________

Address _______________________________________________________

City, State & Postal Code __________________________________________

Information on pet you are applying for:

Dog: Name_______________ Breed___________________ Age_____ Sex____

Description______________________________________________

Cat: Name_______________ Breed___________________ Age_____ Sex____

Description______________________________________________

Veterinarian Name and Address ________________________________________________________________

Do you have any other pets? o Yes o No

If so, how many?______ Are any of them spayed/neutered?______

Would you be interested in assistance for those pets at a later time? o Yes o No

By signing, you are attesting that the information given on this application is

accurate to the best of your knowledge.

Your Signature _____________________________ Date __________________