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2. Public Spay and Neuter Application
   
4. NOTE: All animals that participate in our program will receive a small green tattoo to indicate they are spayed/neutered.
6. Date
   Date
7. In order to sign up for our spay/neuter services you must be at least 18 years old. Are you at least 18 years or older?*
   -- Select One --YesNo
9. Animal's Name*
10. Animal Breed*
12. Animal's Color*
13. Animal's Age*
14. Animal's Weight*
16. Animal's Sex*

    1. Male
    2. Female
17. Animal Type*

    1. Cat
    2. Dog
    3. Other
18. Collar Color
20. Distinguishing Characteristics
22. Has the animal bitten anyone in the past 10 days?*

    1. Yes
    2. No
23. If yes, did it break skin?*

    1. Yes
    2. No
25. Circumstances of the bite
27. Does this animal have any behavioral/medical issues we should know about? (I.E. vomiting, diarrhea, coughing, sneezing, fear biting, aggression, etc.) Please explain:
29. If the animal is a cat, is it feral?*

    1. Yes
    2. No

    If yes, rabies vaccination and an ear tip are required.
31. If your cat spends time outside we encourage ear tipping, that indicates it has been spayed/neutered and vaccinated. Would you like us to ear tip the cat?

    1. Yes
    2. No
33. Current medication(s) and dosage(s):
35. Vaccination Status: We recommend vaccination before surgery for your pets protection (Please provide proof of current vaccination history, although vaccination is not required for surgery.)
37. Medical History: If your pet is currently being treated for seizures, heartworm disease, cardiac issues, or any other preexisting condition, please note that because of the risk involved, these conditions automatically disqualify them for sterilization at our shelter.
39. My pet DOES or DOES NOT have any pre-existing conditions.*

    1. Does
    2. Does not
41. If you would like us to vaccinate your pet please mark which vaccines you would like and prices are listed:*

    1. 1 year Rabies: $10
    2. Canine Distemper-Parvo Vaccine: $10
    3. Canine Bordetella: $10
    4. Feline Distemper: $10
    5. No Vaccines
43. Owner's First Name*
44. Owners Last Name*
46. County*
47. Phone #*
49. Email*
51. Mailing Address*
53. City*
54. State*
55. Zip*
57. Physical Address
59. City
60. State
61. Zip
63. I authorize that this information is correct and current to the best of my knowledge. The Farmington Regional Animal Shelter will not be held liable for any circumstances including the death of my pet if any of this information has been falsified. If you miss your sterilization appointment without give 48 hours of advanced notice you will forfeit your payment.
65. Electronic Signature*
67. Income & Residency Verification:

    Household incomes over $60,000/yr do not qualify for our program. The program is income based and uses household income to determine eligibility and price. You must upload Proof of Income in the form of a filed tax return, Medicaid/Medicare card, or reduced school lunch program for proof of income. You must also upload Proof of Residency such as a utility bill.

69. Submit your income verification and proof of residency.*
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field