Pet Relinquish Form - Animal Education & Rescue

Current Owner Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Main Phone #*

Alternate Phone #

Please select the type of animal are surrendering*

This Pet is*

If "other" please explain*

By what date must you surrender the pet?

Surrender Reason*

Breed	Sex - M/F/Unknown	Coloring	Weight	Age	Spayed/Neutered Y/N

Vet's Name

Phone

City

State

Is the animal up to date on vaccines? If so which ones?*

Health Issues*

Please check all that apply and use the box below to explain any of the conditions you checked.

Please explain any of the health issues you checked above and anything else you can tell us with regard to the medical history of the pet

Has your pet ever bitten a person or another animal?*

If Yes, please explain*

Is the dog/cat good with -

Check all that apply, if unsure do not check

Is the dog housebroken?*

Is the dog crate trained?*

Behavior Issues?*

Check all that apply

Please provide an explanation of any of the behaviour issues checked above or others not on the list

Comments

Please tell us any other information you would like to convey with regard to the pet you are surrenduring

How did you hear about us?*