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Spay\/Neuter Assistance Application<\/h3><\/div><\/div>
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Name<\/label>
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Address<\/label>
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Apt, suite, etc.<\/label><\/div>
Country<\/label><\/div>
State<\/label><\/div><\/div><\/div><\/div>
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Home Phone<\/label>
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Cell Phone<\/label>
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Email Address<\/label>
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Do you live within Gunnison city limits?<\/label>
Yes<\/label><\/div>
No<\/label><\/div>
Don't know<\/label><\/div><\/div><\/div><\/div>
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I am requesting a Spay\/Neuter Assistance Program Coupon in the amount of (choose ONE only):<\/label>
Cat Neuter Coupon for $60 off cost of the procedure<\/label><\/div>
Cat Spay Coupon for $85 off cost of the procedure<\/label><\/div>
Dog Neuter Coupon for $130 off cost of the procedure<\/label><\/div>
Dog Spay Coupon for $160 off cost of the procedure<\/label><\/div><\/div><\/div>
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I am applying for:<\/label>
Cat Neuter<\/label><\/div>
Cat Spay<\/label><\/div>
Dog Neuter<\/label><\/div>
Dog Spay<\/label><\/div><\/div><\/div><\/div>
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Dog spay only<\/label>
Yes<\/label><\/div>
No<\/label><\/div><\/div><\/div><\/div>
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Does this dog weigh over 40 pounds?<\/label>
Yes<\/label><\/div>
No<\/label><\/div><\/div><\/div><\/div>
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Applicant - please read carefully before submitting:<\/label>
I am applying for a Spay\/Neuter Funding Certificate through the GVAWL Spay\/Neuter Assistance Program. I
\nunderstand that this program is intended to provide financial assistance to those for whom spaying or
\nneutering a pet is a financial hardship.<\/p>\n<\/div><\/div><\/div>
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Has anyone in your household applied for, or received, a GVAWL Spay\/Neuter Funding Certificate within the past twelve months?<\/label>
Yes<\/label><\/div>
No<\/label><\/div><\/div><\/div><\/div>
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Household Income<\/label>
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Income Period<\/label>
Monthly<\/label><\/div>
Annually<\/label><\/div><\/div><\/div><\/div>
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Upon submission, I verify that the information above is true. If requested by GVAWL, I agree to provide documentation of my income and financial need.<\/label>
Prohibition Against Discrimination. Any person who seeks to volunteer for or who receives services from the Gunnison Valley Animal Welfare League will not be discriminated against on the basis of ethnic background, color, religion, age, gender, or sexual orientation.
\nRev Sep 2014<\/p>\n<\/div><\/div><\/div>
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Security Check *<\/span><\/label>
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reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div>
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