FIXOKEMAH-Form

FIX OKEMAH APPLICATION

The spay/neuter incentive program open to Okfuskee County residents.

YOUR INFORMATION

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Phone Type *

Email *

DO YOU LIVE WITHIN OKEMAH CITY LIMITS? *

PET INFORMATION:

Pet's name: *

TYPE OF ANIMAL *

MALE OR FEMALE? *

BREED: *

COLOR/DESCRIPTION: *

AGE: *

HOW LONG HAVE YOU OWNED? *

SIZE? (FOR TRANSPORTATION) *

ESTIMATED WEIGHT: *

VACCINATIONS CURRENT? *

HEARTWORM PREVENTION? *

KEPT INDOOR OR OUTDOOR? *

IS PET ALLERGIC TO ANY MEDICATIONS *

IF YES WHAT KIND? *

FEE: *

$35 PER CAT/$45 PER DOG (OPEN TO ALL) $20 PER ANIMAL (INCOME RESTRICTIONS)

*Cost is $35 per cat and $45 per dog . This includes spay or neuter, deworming and vaccinations.
*If you have $12,000 or less total household income (must show proof) cost will be $20 per animal.

PROOF OF INCOME (FOR REDUCED RATE ONLY): *

Max file size: 20MB

UPLOAD PROOF OF INCOME HERE IF YOU ARE APPLYING FOR THE REDUCED RATE OR EMAIL IT SEPERATELY TO fixokemah@gmail.com AND BE SURE TO INCLUDE YOUR FULL NAME IN THE EMAIL SO WE CAN CONNECT IT TO YOUR APPLICATION. YOU CAN ALSO DROP IT OFF AT THE L&M PITT STOP, 700 W Columbia, Okemah Monday-Saturday from 6am-10pm

SIGNATURE & CERTIFICATION

I agree to indemnify and hold harmless Animal Rescue League of Okemah, their volunteers and anyone assisting with transporting my animal to and from the clinic on the day of procedure for any loss or damages that may occur during services rendered.

I understand that this application is only the first step and does not automatically mean I am accepted to the program, and that an A.R.L.O representative will contact me further about the status of my application before any payment is due. *Due to the nature of our funding the available slots are limited.

SIGN YOUR FULL LEGAL NAME HERE TO ACKNOWLEDGE THE ABOVE TERMS AND CONDITIONS *

READ AND ACCEPT BEFORE SUMBITING *

I ACKNOWLEDGE THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

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