Your Information Which of the following are you participating in: Food StampMedicaidTANFSSINone **Proof of income needed: For example, copy of a paystub, letter of assistance, etc. A copy of your driver's license is required upon submission of this application within 1 business day. If your driver's license does not reflect your current address, please provide a copy of a utility bill showing your name and the correct address. Please send your proof of income and your driver's license either email to info@mvhclinic.org or fax it to (540) 260-3233. Pet Information What type of pet do you have? —Please choose an option—CatDog What is your pet's name? What sex is your pet? —Please choose an option—MaleFemale How old is your pet? Is your pet spayed or neutered? YesNo What is your pet's approximate weight? Has your pet been on any medications in the last 30 days? —Please choose an option—YesNo Does your pet have a history of seizures/heart murmur? —Please choose an option—YesNo Has the pet in need of vaccines, ever had vaccines or other veterinary treatment? —Please choose an option—YesNo If yes, name of vet: City/State: How Did You Hear About Us? —Please choose an option—Animal ControlDon't rememberDrove by the BuildingEventFlyer/PostcardMountain View WebsiteFacebookCraigslistMailer NewspaperOther nonprofit/agencyPhone BookRadioRescue OrganizationTransport truckTVVeterinarianSomeone told me about you Any Additional Information Please note: Mountain View Humane's Vaccination Clinic Aid Application funds are only available one time per year, per pet. Required: It is state law that your pet's rabies vaccination be current or updated at the time of receiving services. Would you like to receive E-Newsletters from Mountain View Humane? YesNo I HEREBY GIVE MOUNTAIN VIEW HUMANE CONSENT TO COMMUNICATE WITH ANY OTHER PERSONS OR PARTIES CONCERNING MY HISTORY FOR THE PURPOSE OF VERIFYING THE INFORMATION ON MY APPLICATION. I CERTIFY THAT THE ABOVE NAMED ANIMALS ARE OWNED BY ME PERSONALLY. IF APPROVED, I WILL BE NOTIFIED BY MOUNTAIN VIEW HUMANE. I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR PAYMENT OF ANY AMOUNT ABOVE THE VACCINATION CLINIC ASSISTANCE. Applicant signature: Date: 53 West Main Street, Christiansburg, VA 24073 (540) 382-0222