Behavior Intervention Training Voucher Application

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Owner's Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Observed behavioral issue (Please provide as much detail as possible)*
Where did you hear about this program?*
Upload photo of your Driver's License or Utilities Bill
Must be able to prove residency in Chaffee County for this program.
Accepted file types: jpg, jpeg, png, gif.
Dog's Name*
Please choose:*
- Male
- Female
Please choose:*
- Spayed/Neutered
- Not Spayed/Neutered
- Unknown
Approximate Weight*
Approximate Age*
Primary Color:*
Primary Breed:*
Secondary Breed:
Please attach a photo of your pet
Max. file size: 64 MB.
Date
MM slash DD slash YYYY
Signature*
The person submitting this form agrees that the information on this form is correct and allows Ark-Valley Humane Society to share the information provided with the supporters of the program (private parties, foundations, governments) for the purpose of documenting this behavior intervention training program. You’ll receive a follow up email in a few days.
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