Paws Hoofs and Claws (PHC) Inc - Application for Desexing - Phase Two
I am applying as:
*
My household earns under $60,000 per annum
I am in financial hardship
APPLICANT DETAILS
First name:
*
Last name:
*
Address:
*
Home phone:
Mobile phone:
*
Email Address:
*
Alternate contact person:
*
Alternative contact phone number:
*
Are you currently working?
*
No
Yes
If unemployed, what type of benefit are you on?
Do you hold one of the following concession cards?
QLD Pensioner concession card
Seniors card
Health care card
Veteran card
EXPLANATION
Please give a detailed explanation why you are applying for desexing for your animal/s:
*
ANIMAL #1
Pet name:
Type of pet:
Dog
Cat
How old is the pet?
Breed:
Colour/markings:
Sex:
Male
Female
If female, is your animal on heat/in season or pregnant?
Possibly on heat/in season
Pregnant
Not pregnant
Unsure
Is the pet microchipped?
Yes
No
Unsure
Is the pet registered with the Council?
Yes
No
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
ANIMAL #2
Pet name:
Type of pet
Dog
Cat
How old is the pet?
Breed:
Colour/markings:
Sex:
Male
Female
If female, is your animal on heat/in season or pregnant?
Possibly on heat/in season
Pregnant
Not pregnant
Unsure
Is the pet microchipped?
Yes
No
Unsure
Is the pet registered with the Council?
No
Yes
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
ANIMAL #3
Pet name:
Type of pet:
Dog
cat
How old is the pet?
Breed:
Colour/markings
If female, is your animal on heat/in season or pregnant?
Possibly on heat/in season
Pregnant
Not pregnant
Unsure
Sex:
Male
Female
Is the pet microchipped?
Yes
No
Unsure
Is the pet registered with the Council?
Yes
No
Unsure
Are there any health issues relating to this pet? If so, please explain:
Is the animal friendly towards ALL people?
Friendly
Not friendly
TERMS AND CONDITIONS
Upon submitting this application I agree that ALL the information provided is correct and I confirm I am a resident of Mount Isa City.
*
No
Yes
I agree to provide valid proof of income/financials in order to qualify for the subsidised PHC desexing program and I will receive further instructions via email.
*
No
Yes
I understand that completion of this application does not constitute approval. All applications will be reviewed and determined by the PHC Committee who may also seek or hold further discussions with me to determine eligibility.
*
No
Yes
I acknowledge that if approved there may be a nominal fee and I agree to pay this fee prior to having my animal/s desexed.
*
No
Yes
If my animal is not registered with the Council, I agree to have this completed after desexing and provide PHC with confirmation of my pets council registration number.
*
No
Yes
I am aware of and willing to accept risks associated with general anaesthetic procedures and I will discuss this with the vet.
*
No
Yes