PUP Program Spay request for mom Step 1 of 3 33% CONTACT INFORMATIONPet Owners Name* First Last Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Contact Number* ANIMAL INFORMATIONAnimal Name (s)*Animal Information*CatDogCATS ONLY - Do you have a cat carrier to transport your cat?YesNo - Will need to borrow one from the SPCANo - but I will borrow one from a family member or freindWeight Range - FOR DOGS ONLY0- 45lbs50 - 100lbs100 + lbsPlease provide us with the approximate weight range of your dog, so we can ensure we assign an appropriate kennel size for your pets visit. Approximate Age?*in yearsColour/Description?Is your animal(s) on any medications?YesNoIf yes, please list medications and reasons for taking them...Is your pet showing any of these symptoms: vomitting, rash or diarrhea?*YesNoHow did you get your pet?* Stray Breeder Kijiji Rescue Group Other Do you currently have a Veternarian?*YesNoIf yes, what is the name of your Vet Clinic?Is this a TNR? (a feral, wild, outdoor cat)*YesNoSee for more information on what TNR means visit: spcans.ca/spca-vet-services/trap-neuter-return/ FINANCIAL INFORMATIONAre you on Public Assistance?*YesNoDo you receive Disability or Unemployment?*YesNoHow many adults live in this household?*18 years and olderHow many children live in this household? (under 18 years old)*Please list the TOTAL annual income of your household ($)*Total combined income in $$CONSENT (click on text below to agree to the statement)* Yes - by submitting this form I hereby cerifty that the information i have provided is truthful and correct to the best of my knowledge. I hereby agree to waive any and all claims for damages against the Nova Scotia SPCA, and any officers, volunteers, or agents of the program in the event of death or injury to the animal during surgery. I also consent to the SPCA contacting me regarding this application.