MICROCHIP APPLICATION

This field is for validation purposes and should be left unchanged.

1. APPLICANT INFORMATION

2. ANIMAL INFORMATION

If multiple animals, complete 1 application for each animal.

Species(Required)
Gender(Required)
Is your animal up-to-date on Rabies shot?(Required)
Is your animal up-to-date on Vaccinations?(Required)
Is your animal Spayed or Neutered?(Required)

3. Please attach the following documentation

Do you have proof of low income eligibility? As per list below(Required)
Low-income verification: 1) Section 8 or other housing subsidy documents,2) SNAP, 3) WIC, 4) PG&E CARES/FERA, 5) SSDI, 6) SSI 7) Unemployment insurance or other general assistance benefits
Low-income verification: 1) Section 8 or other housing subsidy documents,2) SNAP, 3) WIC, 4) PG&E CARES/FERA, 5) SSDI, 6) SSI 7) Unemployment insurance or other general assistance benefits
Max. file size: 256 MB.
Max. file size: 256 MB.
Max. file size: 256 MB.

Limit of 8 cats or dogs total per person.

I hereby fully and completely release, indemnify, and hold harmless Humane Society of the North Bay, its directors, officers, volunteers, agents, servants, and employees from any claim, cause of action or liability of any sort or nature, whether known or unknown, directly arising out of or in connection with the vet services provided for this animal.