Print the following information.  E-mail [email protected] if you have questions regarding the application. 

We are grateful to our participating Veterinarians:

Huston Vet Clinic in Jasper (Hamilton County), Suwannee Oaks Vet Clinic near Branford (Suwannee County), Mayo Town & Country Vet Clinic (Lafayette County), and All Springs Vet Hospital in Wellborn (Suwannee County).  Note:  "All Springs" limits dogs to 50 pounds and under.

 

INSTRUCTIONS:  Read the following important program information.

  • Vouchers are for dogs and cats at least 8 weeks old.
  • Theres no limit on the number of vouchers; however, one application is required for each pet.
  • The applicant must be the pets owner and is the only person allowed to use the voucher.
  • Vouchers will expire 90 days after the date of issuance.  Refunds will not be given unless it is determined that circumstances were beyond the owners control.
  • You will be contacted as soon as possible after we receive and process your application regarding eligibility, the cost (between $10 and $50) and receive further instructions.
  • Vouchers cover the full cost of surgery and anesthesia.   Other procedures, including rabies vaccinations, are the responsibility of the pet owner.
  • No cosmetic surgery or declawing is permitted during the surgery under this voucher.
  • Dogs in heat may not be spayed until the heat cycle is completed.
  • Pregnant dogs may be spayed if the veterinarian has determined it is safe to do so.

 

Answer the following questions, sign and date the application, and mail it to North Florida PAWS, Inc., P. O. Box 9, Jennings, FL 32053-0009.

 

___________________________________    (______)_________-___________

Full Name of Owner                                                      Daytime Phone Number

 

_______________________________    _____________   _____    ___________

(P.O. Box or Street Address, City,  State, and  Zip Code)

 

PETs Name:_______________ Cat or Dog?_____  Male or Female: ______Age:______ 

 

Description of Pet, including color and breed or mix (if known):  Breed:______________

Color or Markings:_____________________________________________________

 

Name of Current Veterinarian, if any:   ___________________________________

 

How many other people live with you?  ___ # of Adults   ____ # of Children under 18

 

What is your gross annual household income?   Include income from all sources:

wages from an employer, social security benefits, retirement annuity, etc.

 Provide details below (page 2).

 

 ___Under $12,000    ___$12,001-15,000    ___$15,001-18,000

 ___$18,001-21,000   ___ $21,000-24,000   (Not available for higher incomes)

 

If you receive government assistance such as Medicaid, SSI, food stamps, WIC, etc.,

provide the identification/account number and the name of the issuing office below.


#_____________________   Office___________________________________

 

Enter your Social Security Number and Drivers License Number for verification purposes

only.  This information will not be shared with any other individual or organization.

 

_______-____-_________     ___________________________     ___________

Social Security Number             Drivers License Number                       Issuing State

 

 

_______________________________________     _____________________

                         Signature of Applicant                                           Date

By signing this application, I authorize North Florida PAWS, Inc., to verify any and

all information I have provided freely and without coercion.  I understand that this

information remains confidential.

 

====================Page 2=====================

 

ANNUAL GROSS INCOME for Applicant and all persons in the Applicants household

 

APPLICANT: $_________     ___________________________________________

                          Annual Total        Source:  Employer (include name and location),

                                                                Social Security, etc. 

                                                                       

APPLICANT: $_________    ___________________________________________

                          Annual Total       Source:  Employer (include name and location),

                                                                Social Security, etc. 

     

 

IN ADDITION TO APPLICANT ABOVE, OTHER MEMBERS OF HOUSEHOLD:

 

_________________________ $_________    ______________________________

Full Name                                         Annual Total   Source:  Employer (include name and 
                                                           location),  Social Security, etc. 

__________________     _____-___-________        _________________   ______

Relationship to Applicant   Social Security Number     Drivers License Number    State

 

_________________________________________       _________________

Signature                                                                                                        Date

By signing this application, I authorize North Florida PAWS, Inc., to verify any and

all information I have provided freely and without coercion.  I understand that this

information remains confidential.

 

 

________________________ $___________   ____________________________

Full Name                                         Annual Total    Source:  Employer (include name and 
                                                           location),  Social Security, etc.

___________________     _____-___-________       _________________   ____

Relationship to Applicant   Social Security Number    Drivers License Number    State

 

_________________________________________       _________________

Signature                                                                                                        Date

By signing this application, I authorize North Florida PAWS, Inc., to verify any and

all information I have provided freely and without coercion.  I understand that this

information remains confidential.

 

 

________________________   $__________  _____________________________

Full Name                                         Annual Total   Source:  Employer (include name and 
                                                           location),  Social Security, etc.

_____________________     _____-___-_______       __________________   _____

Relationship to Applicant      Social Security Number   Drivers License Number        State

 

_________________________________________       _________________

Signature                                                                                                        Date

By signing this application, I authorize North Florida PAWS, Inc., to verify any and

all information I have provided freely and without coercion.  I understand that this

information remains confidential.

 

OTHER INFORMATION YOU NEED OR WISH TO PROVIDE: _____________________

_____________________________________________________________________

_____________________________________________________________________

Home Page | Contact Us |  Breed Rescues | Other Rescues | Spay Neuter | Small Dogs+ | Dog Training | Pet Therapy | New Facility | S/N Application
Copyright � 2006 . All Rights Reserved.

GoDaddy.com
GoDaddy.com is the world's #1 ICANN-accredited domain name registrar!