ࡱ> *,)dddd"SxSx` l *!  APPLICATION CABARRUS SPAY/NEUTER CLINIC Owner Information Name ________________________________________________________________ Address ______________________________________________________________ City __________________________________ State ________ Zip __________ Home ___________________ Work _________________ Cell _______________ Email _______________________________________________________________ Animal Information Name ___________________________________________ Sex _____________ Breed ___________________________________________ Weight __________ Color ___________________________________________ Age _____________ Please Check _____ Female Cat - $100.00 _____ Male Cat - $70.00 _____ Feral Cat - $60.00 _____ Female Dog - $130.00 _____ Male Dog - $120.00 _____ Female Dog (70-100lbs) - $160.00 _____ Female Dog (Over 100lbs) - $180.00 Extra Charges _____ Female Cat  Pregnant - $15.00 _____ Female Dog  Pregnant - $20.00 _____ Male Dog  Only 1 testicle in scrotal sac - $30.00 _____ Male Cat  Only 1 testicle in scrotal sac - $30.00 (FeLV/FIV Combo test is an additional $20 if requested) Additional Items _____ Nail Trim - $6.00 _____ Cardboard carrier - $7.00 _____ Elizabethan Collar - $7.00 Medical History Any known allergies _____________________________________________ Any previous medical/surgical conditions _____________________________ Any previous anesthesia/surgical complications ________________________ Has your dog been heartworm tested: Yes No Results _____________ Has your cat been FELV/FIV tested: Yes No Results _____________ Veterinary Hospital Used ____________________________________________________________________ How did you here about us? TV _____ Newspaper_____ Car_____ Sign _____ Yellow Pages _____ Friend_____ Rescue group_____ Vet_____ DSS_____ Internet_____ Have used us before _______ Fundraising: We are trying to form a fundraising committee. Would you be interested in? Being on the committee: Yes No Helping with fundraising: Yes No Do you have any fundraising ideas? _____________________________________________________________________________________________________________________________________________________________ Mail application to: CSNC PO Box 362 Concord, NC 28026 RvJ n * B  $f||ùxqg`VNG@ OJQJCJ OJQJCJOJQJCJ5OJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJ OJQJCJ OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>* OJQJCJOJQJCJ5>*OJQJCJ 5>* OJQJCJ OJQJCJ" OJQJCJ OJQJCJ"R$ i4@4NormalCJOJPJQJmH <A@<Default Paragraph Font`  ` GTimes New Roman5Symbol3Arial7Verdana;Helvetica 0hKl&Kl&!0" Oh+'08@t,APPLICATION FOR CABARRUS SPAY/NEUTER CLINICOwner ՜.+,0,   "#$%&'(+Root Entry F-1TableWordDocument"SummaryInformation(DocumentSummaryInformation8!