UNchain Winston Fence Build Request

Name

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Best time to call *

How did you hear about us?

How many dogs do you have tethered/chained outside? * *

How many hours per day are they tethered/chained or are they always outside? *

Name & Age of Dog 1: *

Gender *

Male
Female

Size (Small, Medium, Large), Breed, & Approximate Weight *

Is your pet spayed or neutered? With our financial assistance, you are required to have your pet spayed or neutered in order to qualify for a fence. Are you OK with this *

My pet is spayed or neutered.
My pet is not spayed or neutered but I agree to the procedure.
My pet is not spayed or neutered, I agree to the procedure, and I would like assistance to spay/neuter them.

Date of Last Rabies Shot *

Name & Age of Dog 2:

Gender

Male
Female

Size (Small, Medium, Large), Breed, & Approximate Weight

Is your pet spayed or neutered? With our financial assistance, you are required to have your pet spayed or neutered in order to qualify for a fence. Are you OK with this

My pet is spayed or neutered.
My pet is not spayed or neutered but I agree to the procedure.
My pet is not spayed or neutered, I agree to the procedure, and I would like assistance to spay/neuter them.

Date of Last Rabies Shot

If you have more than two dogs, please provide the above required details of the other dogs below:

Name, Age, Size, Weight, Gender, Spay/Neuter Status, and Date of Last Rabies Shot

Is your pet spayed or neutered? With our financial assistance, you are required to have your pet spayed or neutered in order to qualify for a fence. Are you OK with this

My pet is spayed or neutered.
My pet is not spayed or neutered but I agree to the procedure.
My pet is not spayed or neutered, I agree to the procedure, and I would like assistance to spay/neuter them.

Date of Last Rabies Shot

Has your dog(s) ever bitten or attacked a person or other animal? *

Yes
No

Have you ever been cited or charged by Animal Control or have you ever been charged with cruelty to animals? *

Yes
No

If you have more than one dog, will they get along in the same fence or pen? *

Yes
No

What is your monthly income? *

We follow the WIC income level guidelines.

Are you on *

Government assistance
WIC
Unemployment
Disability
Other
None

Can you show proof of income if requested? *

Yes
No

Optional: Proof of Income

Click or drag a file to this area to upload.

Do you OWN or RENT the property? A note from the landlord giving UnChain Winston permission to build is required. *

Own
Rent

Optional: Upload Permission Note

Click or drag a file to this area to upload.

I attest that the above information is true and understand that misinformation is a disqualifier for a fence. I understand that UNchain Winston has sole discretion on approvals and the design of the fence or pen. I agree to make any necessary repairs. UNchain Winston and Forsyth Humane Society is not liable for any incidents/losses/injuries as a result of this project and I am fully responsible for my dog(s). *