2017.05.

08 SENS APPLICATION FORM

SELANGOR NEUTERING SUBSIDY APPLICATION FORM

This APPLICATION FORM for the Selangor Neutering Subsidy is available from
selangorneuteringsubsidy.wordpress.com/form. For applicable procedure, terms and
conditions, visit selangorneuteringsubsidy.wordpress.com/policy.

Kindly complete the Application Form using BLOCK CAPITAL LETTERS in black or blue.
Please post the completed Application Form with the completed veterinarian confirmation
and all required attachments to:

SELANGOR NEUTERING SUBSIDY

PAWS Animal Welfare Society
Pilmoor Estate, Subang Airport Road
47200 Subang, Selangor, Malaysia

To qualify for the subsidy, a completed Application Form with all required attachments must
be received by PAWS Animal Welfare Society no later than 14 days after the date of the Vet
Receipt.

IMPORTANT NOTE:
One animal only per Application. One Vet Receipt per animal.

I, the undersigned, hereby confirm that I have read, fully understand and agree to be
bound by all the procedure, terms and conditions set out in
selangorneuteringsubsidy.wordpress.com/policy; and pursuant thereto, I hereby apply for a
subsidy for the neutering of the animal identified in the PARTICULARS OF NEUTERING
below.

I confirm that I have not received any monetary assistance, donation, subsidy or such like
for the neutering of the said animal from any other source.

Save for my bank account particulars, I grant my consent and agree to the publication of
all or any of my information and/or particulars in this Application Form, the Vet Receipt
and/or attachments hereto, on selangorneuteringsubsidy.wordpress.com and/or on the
Selangor Neutering Subsidy’s Facebook page.

If my application is approved, please pay the neutering subsidy into my account below:

Bank:

Account No:

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I attach herewith the following:

• The original copy of the Vet Receipt

• A copy of the Collage

• A photocopy of my NRIC

_________________
Signature of applicant

Name of applicant: NRIC No:

Mobile No: Email:

Address:

Date:

PARTICULARS OF NEUTERING

Cat/Dog Estimate Age Gender Date of Vet

Receipt

I, the veterinarian undersigned, hereby confirm that I neutered the animal above and I
further confirm that animal above is the same animal appearing in the Collage and
mentioned in my Vet Receipt (No. ________) attached hereto.

____________________
Signature of veterinarian

Name of veterinarian:

Name of vet clinic:

Date:

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