Application for Spay/Neuter Services
P.O. Box 448, Walnut Cove, NC 27052

To qualify for assistance, you must be a resident of Stokes County, you must complete this application in its entirety, SUBMIT PROOF OF INCOME, and email or mail all information to the above address.If your application is approved, you will be notified by phone for further information. The pet that is approved has to have proof of a current rabies vaccine. If your pet has not been vaccinated, the rabies vaccine will be given at the time of surgery AT THE OWNERS EXPENSE. State law requires a current rabies vaccination for any dog or cat four months or older. You will also be responsible for transporting the animal to and from the facility providing the
spay/neuter surgery.

Name *
Your answer
Address *
Your answer
City *
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State *
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Zip *
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Telephone (Home)
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Telephone (Cell)
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Email Address
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Marital Status *
Required
List every member living in your household (First and Last Name, Age) *
Your answer
Total Family Income Per Year $ *
(Must send proof of yearly income before application can be processed.)
Your answer
Summary of Family Income Per Year *
(In addition to total income, please list each person individually that receives an income. Include the amount and the source, such as: Employment, SSI, Disability, Child Support, etc. For Example: Jane Smith, $500 per month, SSI)
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Do you have *
Required
Place of Employment *
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Address *
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Telephone Number *
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How long have you been employed by this company? *
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How many animals do you currently own? *
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Please fill in the information on ALL the animals that you own below. *
Dog or cat, name, age, sex, breed, last distemper shot, last rabies shot, feline leukemia tested and spayed or neutered.
Your answer
Which animals are you requested assisted spay/neuters? (List animals needing spay/neuter)? *
Please include the animal's age, weight (dogs only), breed (cat: specifiy short, medium, or long hair), and color.
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Any additional information that you would like for us to consider:
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I understand the above requirements and certify that the information on this application is correct to the best of my knowledge. I understand that failure to disclose information or complete this application in its entirety will forfeit the agreement between the applicant and Spay Stokes. *
Signature & Date
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