Spay/Neuter Clinic Application

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Oktibbeha County Humane Society
P.O. Box 297 ▪ Starkville, MS 39760 ▪ 662-338-9093
http://www.ochsms.org

Email *

Your Contact Information:

Name (First, Middle Initial, Last): *

Street Address: *

City: *

State: *

Zip Code: *

County: *

E-mail Address:

Phone Number: *

This phone number a: *

Cell Phone (CAN receive/reply to text messages)

Cell Phone (CANNOT receive/reply to text messages)

Land Line

Alternative Phone:

Name of your pets' veterinarian: *

Family Size Information

To be eligible for this service you must meet income level requirements. Proof of income for your entire income-earning household must be provided on day of surgery. Acceptable proof includes governmental assistance, tax returns, employment verification with annual salary.

Including yourself and all children, how many people are in your household? *

One (1)

Two (2)

Three (3)

Four (4)

Five (5)

Six (6)

Other:

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