NSNRT Application Form
Thank You For Your Interest!
Please fill out the following information to help us assess whether the National Spay/Neuter Response Team (NSNRT) model is right for your community.

All information needs to be completed at one time, so please digest the full application before beginning to complete your information.

Contacts
Please supply the details for two contacts, where possible.
Contact #1 First Name
Your answer
Contact #1 Last Name
Your answer
Contact #1 Title/Position
Your answer
Contact #1 Work Phone
Your answer
Contact #1 Cell Phone
Your answer
Contact #1 Email
Your answer
Contact #2 First Name
Your answer
Contact #2 Last Name
Your answer
Contact #2 Title/Position
Your answer
Contact #2 Work Phone
Your answer
Contact #2 Cell Phone
Your answer
Contact #2 Email
Your answer
Organization Details
Organization Name
Your answer
Clinic Name
If this differs from the organization name
Your answer
Organization Street Address
Your answer
Organization City
Your answer
Organization State/Province
Your answer
Organization Zip Code
Your answer
Organization Country
Organization Email
Your answer
Organization Phone Number
Your answer
Organization Website
Your answer
Organization Goals
Please describe specific goals achieved by your organization.
Your answer
Surgical Goals
What is your goal for the number of surgeries you will perform annually?
Your answer
501c3 Organization
Are you currently a 501c3 organization?
EIN Number
If you responded yes to the previous question, please provide your EIN number.
Your answer
Municipal Animal Control
Are you currently a municipal animal control?
FEIN Number
If you responded yes to the previous question, please provide your FEIN number.
Your answer
Curent Surgeon/Clinic
Who currently performs the spay/neuter services for your organization?
Your answer
Available Funds
Does your organization have the ability to raise at least $125,000 for the start-up costs of this clinic? This covers $85,000 for equipment costs, $5,000 for travel costs, and $35,000 cash-on-hand to cover operational expenses while you reach surgical capacity.
Secured Facility
Have you secured your facility?
Facility Ready?
Does the facility need to be renovated?
Renovations To Be Completed
If your facility needs to be renovated, when do you anticipate it will be completed?
Your answer
State's Facility Requirements
Please state yes or no to indicate whether or not you know your state's requirements for this type of facility. This information is available in your state's veterinary practice act. It is your organization's responsibility for understanding your state regulations regarding your state's veterinary practice act and state pharmacy laws, as well as keeping up with any changes. Each state is different and you should periodically check to ensure you are in compliance. You should consult an attorney for legal advice on compliance of laws.
Your answer
Practice Ownership
In your state, does a veterinarian have to own your clinic practice?
Secured Veterinarian
Have you secured your veterinarian?
Selected Executive Director
Have you selected your executive director?
Planned Opening Date
What is your planned clinic opening date (e.g. 10/31/15)?
Your answer
Local Population
The Humane Alliance model is designed for clinics to be financially sustainable and high volume. Industry standards place high volume at 5,000 surgeries per year and above. Clinics generally break even doing between 5,000 (25 surgeries per day x 4 days per week x 50 weeks per year) and 8,400 surgeries per year (35 surgeries per day x 5 days per week x 48 weeks per year). In order to accomplish a sustainable surgical goal, we suggest you have a minimum human population of 250,000 within a 60-mile radius of your proposed clinic site. This model can be done with a smaller population and volume, but we would want to talk with you to discuss the details.
Population: County
What is the population of your county?
Your answer
Population: 60-Mile Radius
What is the population in a 60-mile radius around the proposed clinic site?
Your answer
Private Practice Pricing
Please list the average pricing based on a sampling of full-service, private practice veterinarians in your area.
Canine Spay
What is the average fee charged for a canine spay in your area (e.g., $300)?
Your answer
Canine Neuter
What is the average fee charged for a canine neuter in your area (e.g., $200)?
Your answer
Feline Spay
What is the average fee charged for a feline spay in your area (e.g., $175)?
Your answer
Feline Neuter
What is the average fee charged for a feline neuter in your area (e.g., $100)?
Your answer
Existing Spay/Neuter Capacity
What affordable spay/neuter services are currently available in a 2-hour radius of your area? For example, stationary clinic, mobile clinic, shelter clinic, private veterinarians (specializing in spay/neuter), voucher programs, or other. Provide details on the top 3 programs. If there are no programs, please just mark N/A.
Type of Program #1
Estimated Monthly Volume #1
How many spay/neuter surgeries does this service provide each month?
Your answer
Distance #1
How far is this service from your proposed location?
Your answer
Comments #1
Provide any details you think to be pertinent (pricing, appointment wait times, income restrictions, only for shelter animals, only open 2 days per week, etc.)
Your answer
Type of Program #2
Estimated Monthly Volume #2
How many spay/neuter surgeries does this service provide each month?
Your answer
Distance #2
How far is this service from your proposed location?
Your answer
Comments #2
Provide any details you think to be pertinent (pricing, appointment wait times, income restrictions, only for shelter animals, only open 2 days per week, etc.)
Your answer
Type of Program #3
Estimated Monthly Volume #3
How many spay/neuter surgeries does this service provide each month?
Your answer
Distance #3
How far is this service from your proposed location?
Your answer
Comments #3
Provide any details you think to be pertinent (pricing, appointment wait times, income restrictions, only for shelter animals, only open 2 days per week, etc.)
Your answer
Partner Organization Information
In order to achieve your surgical goals (and be sustainable), clinics will need to partner with other humane groups. These partners support your clinic goals by sending their adoption animals, promoting your clinic, offering vouchers, or organizing transports to the clinic. Please detail the top three potential partners in a 60-mile radius from your proposed clinic.
Type of Organization #1
Sterilization Program #1
Does this group have a mandatory pre-adoption sterilization program?
Planned Partnership #1
Have you talked to this organization about bringing animals to your clinic?
Number of Animals #1
If yes, how many animals do you anticipate them bringing each month?
Your answer
Type of Organization #2
Sterilization Program #2
Does this group have a mandatory pre-adoption sterilization program?
Planned Partnership #2
Have you talked to this organization about bringing animals to your clinic?
Number of Animals #2
If yes, how many animals do you anticipate them bringing each month?
Your answer
Type of Organization #3
Sterilization Program #3
Does this group have a mandatory pre-adoption sterilization program?
Planned Partnership #3
Have you talked to this organization about bringing animals to your clinic?
Number of Animals #3
If yes, how many animals do you anticipate them bringing each month?
Your answer
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