First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

Name of Pet*

Type of Pet

What is the breed of this pet? If mixed or not known, what is your best guess?*

Sex

Approximate Birthdate of Pet*

What is the approximate weight of this pet?*

How long have you had this pet?*

Where did you acquire this pet? Please give name of Breed, Shelter/Rescue, or Pet store if applicable.
If FOUND, please list location and date.*

Reason for Surrender*

Pet Traits (Check all that apply)

What commands does this pet know? Please check all that apply, including training history.

Where does this pet stay when no one is home? (Check all that apply)

What is the longest amount of time this pet has been without a human in the home? What is the average amount of time each day that he/she is without a human?*

Reaction to People

If you answered "Good with kids" for previous question, please list age range of children to which pet has been exposed and what is reaction? Do you recommend children for this pet and why?*

Reaction to Other Animals

Please list the other pets in the home, including breed, age, and any serious chronic medical conditions, physical impairments, or behavior issues.
(This information helps us to determine if or what in the environment may be contributing to any behavior issues, and helps us to assess the tolerance
of the surrendered pet for future placement in a home.)*

If the pet you are surrendering is aggressive to other pets, OR is being attacked by other pets, please describe what steps have been taken, and if any have been successful.
(For example: Contacted trainer, breeder/rescue, veterinarian, used medications, separated pets, etc).
Enter "N/A" if aggression is not an issue.*

Please list any known health issues this pet has, and any medications he/she requires.*

Name and number of veterinarian (enter N/A if never seen by vet).*

Please explain the daily pet routine that you currently have with this pet (feeding, sleeping, crating, pottying routines, etc).
Even if you have only had this pet for a short time, this is helpful information.*

Please list any other information that you think would be best help us match this pet with a home (positive and negative).

By signing below, I acknowledge the following:

• I am the owner of this animal and have full right to surrender him/her and that I am hereby releasing all rights for this animal to Pet Adoption Services, Inc.
• I certify that I have provided information to the best of my knowledge to give this pet the best chance at being matched with an appropriate home and that
  falsifying/omitting information about known issues may put this pet, and other individuals and pets at harm. 
• I agree that entering my name below will serve as my signature.

Please enter first and last name.*

Date*