Your Information
Are you participating in the Food Stamp Program, Medicaid, TANF or SSI
Pet Information
Dog

Dog Over 60 lbs
Cat
Sex
Rabies Up To Date?
Has your pet been on any medications in the last 30 days?
Does your pet have a history of seizures/heart murmur?
How Did You Hear About Us?

Any Additional Information
Required: It is state law that your pet’s rabies vaccination be current or updated at the time of receiving services donated through Mountain View Humane. Mountain View Humane aid funding may or may not include the cost of a rabies vaccine, depending on the amount awarded. MVH also requires that each animal receive pain medication to take home. This also may not be covered. I HEREBY GIVE MVH THE CONSENT AND AUTHORITY REQUIRED TO COMMUNICATE WITH ANY OTHER PERSONS OR PARTIES CONCERNING MY HISTORY FOR THE PURPOSE OF VERIFYING THE INFORMATION ON MY APPLICATION OR AS NEEDED TO SECURE FUNDING FOR MY AID APPLICATION. I CERTIFY THAT THE ABOVE NAMED ANIMALS ARE OWNED BY ME PERSONALLY. IF APPROVED, I WILL BE NOTIFIED TO SCHEDULE THE APPOINTMENT. IF NO APPOINTMENT IS MADE WITHIN 48 HOURS OF NOTIFICATION, MVH HAS THE AUTHORITY TO NO LONGER HONOR THE AID OFFERED. EMAIL SUBMISSION OF THIS APPLICATION CONSTITUTES A SIGNATURE.