PET PROFILE SURRENDER APPLICATION
First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone*
Cell Phone*
Alt Email
Pet name*
What species is your pet?* Choose one: Cat Dog
Animal's Age*
Breed*
Coloring*
Sex*
Spayed/Neutered?*
Microchipped?
Microchip number:
What is the name of the company under whom your pet is microchipped?
How long has your pet lived with you?*
Veterinarian's Name*
Veterinarian's Phone Number*
Vaccinations up to Date?*
Date of last Heartworm Preventative*
Date of last Flea and Tick Preventative*
Please confirm your age.
Why are you surrendering or returning this pet?*
Where did you get this pet? If a rescue or breeder, please provide the name.*
House Training (1 is low, 5 is high)*
Description
Crate Training: (1 is low, 5 is high) *
General Activity Level (1 is low, 5 is high)*
Leash Walking (1 is low, 5 is high)*
Good with dogs? (1 is low, 5 is high)*
Good with cats? (1 is low, 5 is high)*
Good with adults? (1 is low, 5 is high)*
Good with children?*
Has this pet ever bitten a person or another animal?*
If your pet has bitten someone, please explain.
Basic Training: What does he/ she know?*
Does he/ she 'guard' anything (eg. Food, treats, toys) If so, what?*
Additional comments
Is your cat litter box trained?
Are there any issues with your cat going outside of the litter box?
What brand/type of litterbox and litter is your cat used to?
By typing my first and last name below, I certify that the information I have given is true and I recognize that any misrepresentation may result in rejection of my application. This serves as my legal signature, and authorizes The Greater Derry Humane Society to verify all information provided.*