Submitted by Lisa on Mon, 01/06/2020 - 11:04 How did you hear about the Lewyt Spay/Neuter Fund? - Select -Saw it on FacebookSaw it on NHHS websiteNHHS staff suggestedFriend/relative suggestedOther First Name * Last Name * Email * Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Day Phone * Evening Phone Preferred Contact Method * Phone Email Are you interested in Microchipping your animal(s)? [$25 fee/animal] Yes No Cats: Are you interested in a FIV/FeLV/HW test? [$25 fee/animal] Yes No Dogs: Are you interested in a Heartworm test? [$25 fee/animal] Yes No No. of Animals you are applying for [5 max.]: * --- ANIMAL #1 -------------------------------- Animal #1) Name * Animal #1) Gender * Male Female Animal #1) Species * Dog Cat Animal #1) Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015201620172018201920202021 Animal #1) Breed * Animal #1) Color/Pattern * Animal #1) Pregnant/Nursing * Yes No Animal #1) Weight (lbs) * Animal #1) Last Rabies Vaccination Date (enter None if never done) * Animal #1) Last Distemper Vaccination Date (enter None if never done) * --- ANIMAL #2 -------------------------------- Animal #2) Name Animal #2) Gender Male Female Animal #2) Species Dog Cat Animal #2) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015201620172018201920202021 Animal #2) Breed Animal #2) Color/Pattern Animal #2) Pregnant/Nursing Yes No Animal #2) Weight (lbs) Animal #2) Last Rabies Vaccination Date (enter None if never done) Animal #2) Last Distemper Vaccination Date (enter None if never done) --- ANIMAL #3 -------------------------------- Animal #3) Name Animal #3) Gender Male Female Animal #3) Species Dog Cat Animal #3) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015201620172018201920202021 Animal #3) Breed Animal #3) Color/Pattern Animal #3) Pregnant/Nursing Yes No Animal #3) Weight (lbs) Animal #3) Last Rabies Vaccination Date (enter None if never done) Animal #3) Last Distemper Vaccination Date (enter None if never done) --- ANIMAL #4 -------------------------------- Animal #4) Name Animal #4) Gender Male Female Animal #4) Species Dog Cat Animal #4) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015201620172018201920202021 Animal #4) Breed Animal #4) Color/Pattern Animal #4) Pregnant/Nursing Yes No Animal #4) Weight (lbs) Animal #4) Last Rabies Vaccination Date (enter None if never done) Animal #4) Last Distemper Vaccination Date (enter None if never done) --- ANIMAL #5 -------------------------------- Animal #5) Name Animal #5) Gender Male Female Animal #5) Species Dog Cat Animal #5) Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20112012201320142015201620172018201920202021 Animal #5) Breed Animal #5) Color/Pattern Animal #5) Pregnant/Nursing Yes No Animal #5) Weight (lbs) Animal #5) Last Rabies Vaccination Date (enter None if never done) Animal #5) Last Distemper Vaccination Date (enter None if never done) Leave this field blank
