Spay/Neuter Assistance Application Attention! All information must be provided with your application or it will not be processed! If you prefer to print and mail your application, please click on the View PDF Form below. View PDF Form Personal Information Your Name Address City, State and Zip Code County Phone # Email How should we send your authorization(s)? E-mailUS Mail Employment Information Place of Employment Monthly Income Spouse's Place of Employment Spouse's Monthly Income Are any other household members employed? YesNo Total Gross Monthly Income (includes alimony, child support, public assistance, retirement, SSI, etc) How many people are supported by this income? Pet Information 1. Pet's Name Type of Pet ---dogcat Sex ---malefemale Breed Age Color/Markings Where did you get the pet? 2. Pet's Name Type of Pet ---dogcat Sex ---malefemale Breed Age Color/Markings Where did you get the pet? 3. Pet's Name Type of Pet ---dogcat Sex ---malefemale Breed Age Color/Markings Where did you get the pet? Do you have more than 3 pets needing spayed or neutered? yes If yes, list additional information here: Please select one of our participating veterinarians. Help for Animals (One Humane Way, Barboursville, WV)Fix 'Em Clinic (102 Dee Drive, Charleston, WV)Fix Charleston (1246 Greenbrier Street, Charleston, WV) Do you have any additional questions or remarks? Instructions If this application is approved, you will receive one authorization form for each pet being spayed or neutered. Once you receive the authorization form(s), call the vet to make an appointment. You must present the authorization form(s) to the vet when you take your pet for its appointment. If you are unable to keep your appointment, you must give at least 24 hours' notice to the vet's office. You Must Read and Acknowledge The Statement Below By typing my name in the line below, I understand all questions on this application must be answered or this application will not be processed. I also certify the accuracy of the information I have provided. Type your name (in lieu of signature) Today's Date Thank you for helping to make your pet a healthier and happier companion, and for helping stop pet over-population. Please call our office at 304.562.0300 if you have any questions.