Polk County Humane Society Request to Surrender Form

Driver's License Number (or other identification)

Are you requesting to surrender a:

Reason for Surrender (Check all that Apply)

Is this a litter? If so, how many in the litter? And, please give info on all pets in the litter below.

Pet's Name

Pet's Gender

Pet's Breed (or your guess of its Breed)

Pet's Size

Pet's Age

Description of Pet (color, fur length, type, ears, tail, etc.)

How long have you had this pet?

If this pet is a stray, when (date and time) did you find it?

If this pet is a stray, where did you find it? Please be as specific as possible. That will help us try to locate an owner.

If this pet is a stray, what efforts have you made to find its owner?

Please include a picture of the pet if you are able.

If this pet is NOT a stray, when & how did you come to possess the pet?

Pet's Diet (check all that apply)

How much have you been feeding? And, how often?

Is this pet neutered/spayed?

Has the pet had any vaccinations? If so, please describe.

Has the pet had any flea/ tick preventative administered? If so, what type and when?

Has the pet had any heartworm preventative administered? If so, what type and when?

Does this pet have any allergies that you know of?

Does this pet have any current or past injuries or illnesses? If so, please describe.

Is this pet on any medications? If so, what medications and how often are they administered?

Is this pet microchipped?

Would you describe the pet as: (check all that apply)

Where has this pet been living?

Does this pet have any of these qualities? (check all that apply)

This pet:

What activities does this pet enjoy?

What commands or tricks does this pet know?

Does this pet get along with? (check all that apply)

Is there any other information we should know about this pet if we are able to take them into our Shelter?

This animal:

If this animal has bitten or injured a person or persons in the past, please describe the number of times and circumstances.

If this animal or litter is accepted for surrender by Polk County Humane Society, I agree that I am voluntarily surrendering the animal. To my knowledge, no other person has any right to this animal. I hereby surrender all rights to this animal. I understand that once I surrender this animal, the animal will not be returned to me.

I understand there is a fee of $25 per pet or $50 per litter due at the time of surrender.

Signature / Date