S.N.A.P.   application

Spay & Neuter Assistance Program

Thank you for your interest in getting your pet(s) fixed! There are too many pets without homes in Pickens County and by getting your pet(s) age 8 weeks and up spayed or neutered, you will help Pickens Animal Rescue, Inc. to reduce this problem in the future.  Our funds are limited and we want to help those pet owners who truly need financial assistance, so if you can afford to pay for the spay/neuter surgery yourself, please allow us to use our funds to provide reduced cost spay/neuters to someone who is truly in financial need. Other low cost options can be found on our website at www.pickensanimalrescue.org.

If you can’t afford the other spay/neuter options and would like to request a $25.00 spay/neuter coupon, then please fill out this form, one form per animal.  This is a request form only, not an approval for a spay/neuter. Return this completed form along with $25.00 per request to Pickens Animal Rescue, PO Box 45, Jasper, GA 30143.  When you receive a coupon in the mail, this will be your go ahead for a spay/neuter. Instructions for obtaining the spay/neuter will be on the coupon. If application is denied, your check will be returned to you promptly.

Please note that this offer is good for Pickens County residents only. Proof of residency will be required.

Please indicate the reason that you need this assistance for $25.00 spay/neuter surgery (circle all that apply):

Receiving Medicaid           Unemployed                Receive Public Assist.            Disability                   
        

Other financial hardship, please explain in detail ______________________________________

Are you the: 

    Owner of the pet?   Yes            No               

    Caregiver?              Yes            No

Other, Please explain ____________________________________________________________

Your Name: ___________________________________________________________________

Street Address: _________________________________________________________________

Home Phone: ________________Work Phone: _______________Cell Phone: ______________

Employers’ Name: ______________________________________________________________

Assistance for:  Dog         Cat
                          Male       Female
     

Age _______ Breed _____________

Name of Pet ___________________ Color ___________ Description _____________________

How long have you owned this pet? ________________________________________________

Where did you obtain this pet originally? ____________________________________________

           
 If found, where was it found? _____________________________________________

           
 Adopted from shelter? Which One? ________________________________________

           
 Purchased from store/breeder? Which One? __________________________________

           
 Purchased from individual?  Cost Involved? __________________________________

           
 Received from friend/relative?  ____________________________________________

Has this animal ever given birth? ___________ If so, what happened to the litter?

______________________________________________________________________________

Do you have other unfixed dogs or cats in your home? _________________________________

If so, do you need financial help with getting them spayed or neutered? ____________________

Do you: 
             Own your home                 Rent                          Live with relatives rent free

How many adults live in your home?  _______  Number of children living in your home? _____

How many pets do you own? ______________  How many are already fixed? ______________

Have you applied for SNAP in the past? ___________ Were you denied or accepted? _________

I hereby certify that the foregoing information is true and correct and that I have not omitted anything which would make my application false or misleading. I will not hold Pickens Animal Rescue, Inc., their veterinarian clinics, directors, officers, employees or volunteers liable for any complications arising from the spay or neuter procedures.

Your signature ___________________________________  Date _______________________

                        (Must be 18 years of older to sign)

Getting your pet fixed is a SNAP!

Pickens Animal Rescue, Inc.      PO Box 45      Jasper, GA 30143

706-692-2772   www.pickensanimalrescue.org