First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Cell Phone

Animal Name, Breed & Color*

Age:*

Please list your veterinarian's name, clinic address and phone number in the space below:*

Please list the dates of your pet's most recent vet visit and most recent shots (name of vaccine and date of each); the date your pet was spayed or neutered and the date of your pet's most recent FIV/FELV test.*

Please indicate the reason you are looking to surrender your pet. Please include any behavior or medical issues you have noted:*

I understand that Dumped Stray Animal Rescue, Inc. will not consider any pet for surrender to our rescue until they are up to date with all vaccines, are spayed or neutered and have a SNAP test for FIV/FELV. I understand that any of these services that are needed prior to surrender, will be at my cost in addition to the standard surrender fee of $150 per animal.