Name *

First

Last

Phone Number *

Address *

Email *

How many animals are you needing assistance with? *

1
2

~HSUV is only able to assist with 2 animals per calendar year due to funding~

Animal type *

Dog
Cat

Gender *

Male
Female
Unknown

What vet clinic is your appointment at? *

What is the date of the appointment? (MUST be already scheduled) *

Appointment MUST be scheduled prior to filling out application and must be AT LEAST 7 days out

What name is the appointment under if it is different than name listed above? *

First Animal's Name *

Second Animal's Name

When requesting assistance for 2 pets

Have you received our assistance in the past? *

Yes
No

If yes, when did we assist last and with how many pets?

The Humane Society of the Upper Valley has a limited number of certificates available and filling out this application does not guarantee a certificate can be provided. Please follow up with your veterinarian listed in the above application for voucher. HSUV requires 7 BUSINESS DAYS notice before the S/N appointment to authorize the certificates to ensure we have a chance to get the certificate to the vet. We may be able to make an exception for feral cats on the notice needed depending on board availability. *

I Understand

Certificate amounts are generally $25 off depending on funding.

E Signature *

First

Last

Date *

Spay and Neuter Assistance Application