$100 Coupon Application

Your Information

Please provide your contact information. The address you provide is where the coupon will be mailed. (Coupons are not sent via e-mail)

Name *

First

Last

Address Field *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Phone *

Email Address (If you are not awarded a coupon a notice will be sent to you via e-mail only)

Pet Information:

Please answer these questions about the pet you are applying for

Pet's Name *

Type of Pet *

Male or Female *

The Animal's Age *

Please Descripe How You Got Your Pet
If You Selected "Other" Please Explain:

If you purchased your pet from a pet store or breeder please state the price you paid, and explain why you can afford to buy a pet but cannot afford to pay for it’s spay/neuter surgery

Is Your Pet Primarily Indoors or Outdoors?

Is Your Pet Current on Vaccinations?

If your pet has a current veterinarian who is it? (You may use the coupon at any of the participating clinics)

I agree that the information I have provided is accurate to the best of my knowledge. I understand that there are a limited number of coupons available, and completing this application does not guarantee that I will receive a coupon. I understand that if I have provided my email address above that I will be notified via e-mail only if I am NOT going to receive a coupon. *

I Agree

The Friends of the Jefferson City Animal Shelter does not directly participate in the animal spay/neuter process. Animals that are spayed or neutered as a result of our reduced cost program are the responsibility of the animal’s owner and the veterinarian. We accept no responsibility or liability for any injury or damage, or claims subsequent thereto, to any person, property, or animal, caused directly or indirectly by any of the participating parties. Any person agreeing to participate in this program assumes full personal responsibility and agrees to this waiver of liability. *

I Agree