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Community Outreach Form
Name of dog's owner or primary caretaker:
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Address
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City:
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County of Residence:
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State:
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Zip/Postal Code:
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Phone Number:
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Email (please use an email address you are able to check often):
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What is your dog's name:
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What is your dog's age?
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What is your dog's weight (lbs)?
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What is your dog's gender?
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What is the breed of your dog?
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Dogs Color
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How long have you had the dog?
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How many other animals living in the home?
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Veterinarian's name?
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Veterinary hospital or clinic name:
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Address:
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City/State/Zip:
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Phone Number:
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Amount requested:
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What services are you needing assistance from SEPR with?
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Spay (female)
Neuter (male)
Vaccinations
Micro-chipping
City License
Education
Behavioral Training
Other
Other
Are there circumstance that we need to be aware of (i.e. termination of pregnancy, pediatric spay, undescended testicle etc.) that would make the procedure more costly? If yes, please explain:
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____________________________________________________________________________________________
How many individuals reside in your home?
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Your average annual household income?
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$0-$10,000
$10,000-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000 +
How much can you contribute toward the cost of surgery?
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Have you applied previously with SEPR for assistance?
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Yes
No
How did you hear about SEPR's spay/neuter assistance program?
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Any additional comments you would like to give for consideration of this application:
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Please attach any current vet records:
Please attach current photo of your pet in need.