<p> Talbot Humane Spay/Neuter Program Application for Financial Assistance P.O. Box 1143, Easton, Maryland 21601 PH(410) 822-0107 FX(410) 822-7619</p><p>In order to be eligible for our program, your pet must have current rabies and distemper vaccination. Talbot Humane, Inc. reserves the right to have the surgery performed by the veterinarian of our choice.</p><p>Each veterinary hospital reserves the right to require specific tests or vaccinations prior surgery. Please check with your veterinarian for specific requirements. Applicant’s Information:</p><p>1. Name ______2. Physical Address______3. Home Phone: ______Work Phone: ______4. Annual Household income: ( ) $10,000 or less CO PAY $25.00 ( ) $10,001 - $20,800 ( ) $20,801- $40,000 ( ) over $40,000 You must provide proof of income. All financial information will be held in confidence. 5. Are you: ( ) married ( ) single? Number of dependents: ______</p><p>Animal information:</p><p>1. Is this application for: ( )dog ( ) cat? Pet’s name______Color______2. Is it ( ) male ( ) female? Is your female possibly pregnant? ______In heat? ______Any extra costs incurred because your pet may be pregnant or in heat will be your responsibility. There may be additional costs incurred due to other medical problems that will also be your responsibility.</p><p>3. Pet’s age: ______Breed: ______4. Is it: ( )small( 5-20 lbs.) ( )Medium( 25-50lbs) ( )Large ( over 50lbs.) 5. Please circle one of the participating veterinarians: Pet Health Clinic Midshore Veterinary Clinic or All Pets Veterinary Services 6. Check the following vaccinations your pet has received in the past year. ( ) distemper ( ) rabies Note: proof must be provided at time of surgery. 7. What other pets do you have? Pets name______( )dog ( )cat Spayed or neutered? ( ) yes ( )no Pets name______( )dog ( )cat Spayed or neutered? ( ) yes ( )no Pets name______( )dog ( )cat Spayed or neutered? ( ) yes ( )no I agree the above information is correct and that the Talbot Humane, Inc. is released from all liability associated with my pet’s surgery.</p><p>Date______Signature______</p><p>OFFICE USE ONLY: RECEIVED: FAXED: CALLED: (Ed. 2/13)</p>