AFRP North Monterey County Small Dog Voucher Application

For owners of small dogs living within North Monterey County, CA
Fill out the form below to apply for SPAY Pal Voucher.

Please provide the following information:

First Name:

Last Name:

Address: Unit Number:

City: State: CA Zip:

Daytime Phone:

Email Address:

What is your gross annual household income? $25,000 or less  $25,001 to $38,000

$38,001 to $48,000  $48,001 or more

Number of dependents (including yourself): 1   2   3   4   5 or more

Please check the appropriate box if you receive public assistance:

Unemployment   Medicaid/Medical   Disability   Social Security   Other   

Are you able to make a co-payment towards your dogs's surgery? Yes   Amount per dog:   No
Recommended co-payments are from $25-$50 per dog, payable to the vet at the time of surgery.

Number of vouchers requested:

dog #1 Name:   Approx. weight:   Breed:

Age:   Color:   M   F

Does this dog have: DHPP (Distemper/Parvo) Vaccine: Yes   No   Rabies Vaccine: Yes   No

Dog #2 Name:   Approx. weight:   Breed:

  Age:   Color: M   F

Does this dog have: DHPP (Distemper/Parvo) Vaccine: Yes   No   Rabies Vaccine: Yes No

Where did you get your dog?:

Has your dog ever had a litter before? Yes   No   If yes, how many times?
How many puppies total?

Have you ever turned a dog into the shelter before? Yes   No   If yes, reason?

  Why have you not altered your dog before? Cost   Didn't think necessary

Are there any other extenuating circumstances that we should know about?

By submitting this form I certify that the above information is truthful and correct.

DHPP (Distemper/Parvo) and rabies vaccines are required by the veterinarians’ offices prior to or will be needed on the day of surgery.

When contacting the vet office please ask about any additional charges that you may be responsible for.

The vouchers are good only for the spay/neuter surgery costs.
Any other charges for exams, pain medidogion, e-collars, vaccinations or other services provided are your responsibility at the time the services are provided.