Grainger County Humane Society

TODAY'S DATE:_____________

CLINIC REQUESTED: (PAL Mobile, Male Cat Neuter Clinic, etc.)_______________________________

DATE OF REQUESTED CLINIC: (see clinic description)______________________________________

Name _____________________________________________________________________________

Address ___________________________________________________________________________

City/State/Zip _______________________________________________________________________

Day Phone __________________________________ Evening Phone___________________________

Cell Phone___________________________________Email Address ____________________________

1.    Pet's Name:______________________________   Dog          Cat          Age:_______________

        Breed:__________________________________  Male  Female       Weight:______________

2.     Pet's Name:______________________________   Dog          Cat        Age:_______________

        Breed:__________________________________   Male  Female    Weight:______________

THESE CLINICS ARE OPEN TO ALL HOUSEHOLDS REGARDLESS of INCOME

By signing and submitting this application, I agree to accept a complimentary "Participating Membership" in the Grainger County Humane Society. Participating Members may receive newsletters and information about upcoming events, meetings, and volunteer opportunities; but do not receive voting privileges.

Applicants signature _______________________________________________DATE:_____________

Please keep my name on file for future spay/neuter clinics._______________Initial

Number of other animals in my care that need spaying or neutering:  Dogs_________ Cats__________

SUBMIT YOUR APPLICATION TO:

Grainger County Humane Society

ATTN:  Spay/Neuter Program Application

P.O. Box 229

Rutledge, TN 37861

You will be notified one week prior to clinic by phone or mail.