First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone

Cell Phone*

Name of pet?*

Please explain the reason why you are surrendering.*

Breed of pet?*

Sex of pet

What is your pet's age?*

Is pet spayed/neutered?

Veterinarian's Name and Phone Number*

Is your pet microchipped?

Is pet UTD with all shots?

(For dogs only) If over a year old, has the dog been tested for heartworms? If so, when? And the results: negative or positive?

Is your pet on monthly heartworm prevention?

Is your pet on monthly flea & tick prevention?

(For cats only) Has your cat been tested for Felv or Fiv? If so, were the results negative or positive?

Is the pet kept inside or outside the home?

Please describe pet's temperament.*

Does your pet have food and/or toy aggression towards other animals or people? *

Is pet good with dogs?

If no please explain.

Is pet good with cats?

If no please explain.

Is pet good with kids of all ages?

If no please explain.

How does pet react to new people? Good with both male and female adults? *

Is the pet destructive inside the house?

If yes please explain.

Is your pet destructive in the yard?

Is pet crate trained?

Does pet have any medical issues?

If yes please explain.

Has your pet ever bitten a person or animal? Please note we will check for bite history with animal control.

Any other information you wish to include?

Failure to answer all questions, or providing false or misleading information will result in your form being denied. Please initial you understand.*

TLCAR is a foster based organization. Completion of this form does not mean we will be able to take the dog in, however we can post your request for a foster home, adopter or another rescue. Please initial you understand.*

Please sign*