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Your Personal Information

* First name

* Last name

* Email

* Phone

Cell number

* Address one

Address two

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

Additional Information

Driver's License Number (or other identification)

Are you requesting to surrender a:

Cat or KittenDog or Puppy

Reason for Surrender (Check all that Apply)

Can't AffordFamily ChangePet's HealthMoving / HousingAllergiesPet's BehaviorLack of Time for this PetAggressionUnwantedStray - This is not my PetOther

Description of Pet(s)

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

MaleFemaleI don't know

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

Pet's Size

SmallMediumLargeExtra Large

Pet's Age

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

How long have you had this pet?

Over 10 years6-9 years3-5 years1-3 years6 months to 1 year2 months to 5 monthsLess than 2 monthsI just found this pet (less than a week)

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.

Pet's Health Information

Pet's Diet (check all that apply)

Dry FoodCanned FoodI don't know

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

Is this pet neutered/spayed?

YesNoI don't know

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?

YesNoI don't know

Pet's Behavior Assessment

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

ActiveCouch PotatoAffectionateQuiet/ShyPlayfulAggressiveTimidFeral/Wild

Where has this pet been living?

IndoorsOutdoorsOther (shop, garage, barn)Out in the open (woods, fields, roads, etc.)I don't know

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

AggressiveBarks or Meows ExcessivelyDigsChewsDestroy's Property or FurnitureEscape ArtistHas Separation AnxietyJumps on PeopleChases

This pet:

Is Housebroken / Litter box trainedIs Crate trainedWalks on a leashTolerates or likes being groomedRides in carSits on your lapBites or scratches people

What activities does this pet enjoy?

What commands or tricks does this pet know?

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

WomenMenChildrenDogsCatsLivestockChickens

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

This animal:

This animal has NOT bitten or injured any person in the past.This animal HAS bitten or injured a person or persons in the past.

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

Signature

I certify that the information included in this surrender request form is accurate and true.

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 own this animal/litter that I wish to surrender.I do not own this animal or it is a stray, but to my knowledge, no other person has any right to this animal.

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

Yes

Signature / Date