Spay & Neuter Assistance Program

Pet Aid Application

Download the Form

Applicant Information

First Name *

Last Name *

Street Address *

City

State/Province

ZIP / Postal Code

Primary Ph: *

Alternate Ph:

Email Address *

Animal Information

Animal's Name:

Breed

Age

Colour:

Approx Weight:

Surgical Procedure Requested *

Female Cat SpayMale Cat NeuterFemale Dog SpayMale Dog Neuter

Current Veterinarian's Name(if applicable)

How many other pets do you have in your household:

How many are spayed and/or neutered:

Cats

Dogs

Household Information

Number of Adults:

Number of Children (under 18):

Total # In Household

For Each Adult in the household, provide a copy of the current, official Canada Revenue Agency Notice of Assessment showing total income (line # 150).

Annual Household Income: *

A signature from EACH ADULT in the household is required on this application. Please be sure to include First Name, Last Name, Signature, AND date in the fields provided.

Please check off the boxes below:

Checkbox *

I (we) have enclosed a copy of the previous year's Notice of Assessment from Canada Revenue Agency for all income earning residents residing in the household for the purpose of assessing eligibility for the Pet Aid Spay & Neuter Assistance Program

I have filled out the application in full and have read the terms of conditions on the backside of this application

I declare that i am the owner of the animal listed on the application and i am of legal age in the province of Ontario. I declare that the information i have given is truthful, complete and correct. I understand that i may be asked to provide proof of income and/or identification; failing to do so, will result in refusal of service from the NHS Pet Aid Program.

Applicant Name *

Signature *

Date *

This section must be completed and signed by each adult related by blood, marriage or common-law living in the household.

Name

Signature

Date

Name

Signature

Date

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NHS Shelter:

2363 Theatre Road
Cobourg, ON K9A 0R3
Phone: 905-885-4131
Fax: 905-885-8027
info@northumberlandhs.com

NHS Thrift Store:

24 Covert Street
Cobourg ON K9A 2L6
Phone: 905-372-8451
thriftstore@northumberlandhs.com