Spay/Neuter Intervention Program

Voucher Application

Fill out one form for each pet (normally limited to two pets per month) and bring to the St. Bernard Parish Animal Shelter with proper identification; do not mail application. The S.N.I.P. Coordinator (Ceily Trog, the manager of the shelter) must approve your application before the pet’s spay/neuter appointment is made. The S.N.I.P. coordinator can be reached at 278-1535 for further information or questions.

Owner Name: _________________________________ Application Date: _________

Address (mailing): ______________________________________________________

City: _____________________________ State: ________ Zip: __________

Home Phone: _______________________ Work/Cell Phone: ____________________

Spouse or Other owner: __________________________________________________

Animal Information: Pet’s Name: ____________________ Sex: M F Age: ______

Species: Dog Cat Breed: _____________________________ Purebred: Yes No

Color(s): ________________ Where was this pet acquired? ____________________

Which Veterinary Hospital do you plan to use? ________________________________

Reason for requesting financial assistance (choose 1):

€ Public Assistance Recipient

€ Senior on low fixed income

€ Unemployment or Workman’s Compensation

€ Other Financial Situation (please explain on back of application)

€ Registered Feral Cat Colony Caretaker (documentation attached)

I understand that application(s) for a Spay/Neuter Intervention Program voucher will be considered by Friends of the Animal Shelter of St. Bernard, Inc. (FOAS) on a first-come, first-served basis, and will be based solely upon availability of funds and the verification of information provided in this application. FOAS has the discretion to determine whether or not a voucher will be given, and has the right to deny any application for any reason. I acknowledge that the amount of this voucher may not cover the full cost of my pet’s spay or neuter operation, and the veterinary hospital may require vaccinations and/or charge more than the voucher’s face value for surgery related services. I agree to pay the veterinary hospital any additional costs relating to the surgery at the time of service, unless previous arrangements have been made with the veterinary hospital.

Owner’s Signature:________________________________________ Date:______________

TO BE FILLED OUT BY SNIP COORDINATOR:

Type/Documentation: _____________________________________ Verified by: __________

Certificate Number: ________ Voucher Amount: ___________ Expiration Date: __________