Cat Surrender Form

Individual or Couple *	Individual Couple
Primary First Name *
Primary Last Name *
Primary Date of Birth *
Primary Cell Phone Number *
Primary Email Address *
Secondary First Name *
Secondary Last Name *
Secondary Date of Birth *
Secondary Phone *
Secondary Email
Address *
City *
State *	AR AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code *
Cat's Name *
Species *	Cat
Sex *	Female Male
Breed (best guess) *	Abyssinian Affenpinscher Afghan Hound African Grey Airedale Terrier Akbash Akita Alaskan Malamute Amazon American American Bulldog American Curl American Eskimo Dog American Fuzzy Lop American Sable American Shorthair American Staffordshire Terrier American Water Spaniel American Wirehair Anatolian Shepherd Angora Rabbit Appaloosa Appenzell Mountain Dog Applehead Siamese Arabian Australian Cattle Dog/Blue Heeler Australian Kelpie Australian Shepherd Australian Terrier Balinese Basenji Basset Hound Beagle Bearded Collie Beauceron Bedlington Terrier Belgian Hare Belgian Shepherd Dog Sheepdog Belgian Shepherd Laekenois Belgian Shepherd Malinois Belgian Shepherd Tervuren Bengal Bernese Mountain Dog Beveren Bichon Frise Birman Black and Tan Coonhound Black Labrador Retriever Black Mouth Cur Bloodhound Bluetick Coonhound Bobtail Bombay Border Collie Border Terrier Borzoi Boston Terrier Bouvier des Flanders Boxer Boykin Spaniel Briard Britannia Petite British Shorthair Brittany Spaniel Brotogeris Brussels Griffon Budgie/Budgerigar Bullmastiff Bull Terrier Bunny Rabbit Burmese Burmilla Caique Cairn Terrier Calico Californian Canaan Dog Canadian Hairless Canary Cane Corso Mastiff Carolina Dog Catahoula Leopard Dog Cattle Dog Cavalier King Charles Spaniel Champagne DArgent Chartreux Checkered Giant Chesapeake Bay Retriever Chicken Chihuahua Chinchilla Chinchilla Chinchilla Chinese Crested Dog Chinese Foo Dog Chocolate Labrador Retriever Chow Chow Cinnamon Clumber Spaniel Clydesdale Cockapoo Cockatiel Cockatoo Cocker Spaniel Collie Conure Coonhound Corgi Cornish Rex Coton de Tulear Cow Crème DArgent Cymric Dachshund Dalmatian Dandi Dinmont Terrier Devon Rex Doberman Pinscher Dogo Argentino Dogue de Bordeaux Domestic Long Hair Domestic Medium Hair Domestic Short Hair Donkey/Mule Dove Draft Duck Dutch Dutch Shepherd Dwarf Dwarf Eared Eclectus Egyptian Mau Emu English Bulldog English Cocker Spaniel English Coonhound English Lop English Pointer English Setter English Shepherd English Spot English Springer Spaniel English Toy Spaniel Entlebucher Eskimo Dog Exotic Shorthair Extra-Toes Cat (Hemingway Polydactyl) Ferret Field Spaniel Fila Brasileiro Finch Finnish Lapphund Finnish Spitz Fish Flat-coated Retriever Flemish Giant Florida White Foxhound Fox Terrier French Bulldog French-Lop Gaited Gecko Gerbil German Pinscher German Shepherd Dog German Shorthaired Pointer German Wirehaired Pointer Glen of Imaal Terrier Goat Golden Retriever Goose Gordon Setter Grade Great Dane Greater Swiss Mountain Dog Great Pyrenees Greyhound Guinea fowl Guinea Pig Hamster Harlequin Havana Havana Havanese Hedgehog Himalayan Himalayan Holland Lop Hotot Hound Hovawart Husky Ibizan Hound Iguana Illyrian Sheepdog Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Italian Spinone Jack Russell Terrier Japanese Bobtail Japanese Chin Javanese Jersey Wooly Jindo Kai Dog Kakariki Karelian Bear Dog Keeshond Kerry Blue Terrier Kishu Komondor Korat Kuvasz Kyi Leo Löwchen Labrador Retriever Lakeland Terrier Lancashire Heeler Leonberger Lhasa Apso Lilac Lizard Llama Lop Eared Lory/Lorikeet Lovebird Macaw Maine Coon Maltese Manchester Terrier Manx Maremma Sheepdog Mastiff McNab Miniature Pinscher Mini-Lop Mini Rex Missouri Foxtrotter Morgan Mountain Cur Mountain Dog Mouse Munchkin Munsterlander Mustang Mynah Neapolitan Mastiff Netherland Dwarf Newfoundland Dog New Guinea Singing Dog New Zealand Norfolk Terrier Norwegian Buhund Norwegian Elkhound Norwegian Forest Cat Norwegian Lundehund Norwich Terrier Nova Scotia Duck-Tolling Retriever Ocicat Old English Sheepdog Oriental Long Hair Oriental Short Hair Oriental Tabby Ostrich Otterhound Paint/Pinto Palomino Palomino Papillon Parakeet (Other) Parrotlet Parrot (Other) Paso Fino Patterdale Terrier (Fell Terrier) Peacock/Pea fowl Pekingese Percheron Persian Peruvian Inca Orchid Peruvian Paso Petit Basset Griffon Vendeen Pharaoh Hound Pheasant Pigeon Pig (Farm) Pionus Pit Bull Terrier Pixie-Bob Plott Hound Poicephalus/Senegal Pointer Polish Polish Lowland Sheepdog Pomeranian Pony Poodle Portugese Podengo Portuguese Water Dog Pot Bellied Prairie Dog Presa Canario Pug Puli Pumi Quaker Parakeet Quarterhorse Ragamuffin Ragdoll Rat Rat Terrier Redbone Coonhound Retriever Rex Rhea Rhinelander Rhodesian Ridgeback Ringneck/Psittacula Rosella Rottweiler Russian Blue Saddlebred Saint Bernard St. Bernard Saluki Samoyed Satin Schipperke Schnauzer Scottish Deerhound Scottish Fold Scottish Terrier Scottie Sealyham Terrier Selkirk Rex Setter Shar Pei Sheep Sheep Dog Shepherd Shetland Sheepdog Sheltie Shiba Inu Shih Tzu Siamese Siberian Siberian Husky Silky Terrier Silver Silver Fox Silver Marten Singapura Skunk Skye Terrier Sloughi Smooth Fox Terrier Snake Snowshoe Softbill (Other) Somali South Russian Ovcharka Spaniel Sphynx (hairless cat) Spitz Staffordshire Bull Terrier Standardbred Sugar Glider Swan Swedish Vallhund Tan Tennessee Walker Terrier Thai Ridgeback Thoroughbred Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Tiger Tonkinese Tosa Inu Toucan Toy Fox Terrier Treeing Walker Coonhound Turkey Turkish Angora Turkish Van Turtle Vietnamese Pot Bellied Vizsla Warmblood Weimaraner Welsh Corgi Welsh Springer Spaniel Welsh Terrier West Highland White Terrier Westie Wheaten Terrier Whippet White German Shepherd Wire-haired Pointing Griffon Wirehaired Terrier Xoloitzcuintle/Mexican Hairless Yellow Labrador Retriever Yorkshire Terrier Yorkie
Color *	Amber Apricot Black Black and Brindle Black and Brown Black and Tan Black and White Black Tortie Blue Blue-Mottled Blue Tortie Brindle Brindle and Black Brindle and White Brown Brown and Black Brown and White Chocolate Chocolate Tortie Cinnamon Cinnamon Tortoiseshell Cream Fawn Fawn Tortoiseshell Ginger Ginger and White Golden Green Grey Grey and White Light Amber Lilac Lilac Tortie Liver Liver and White Red Speckle Ruddy Seal Silver Sorrel Sorrel Tortoiseshell Tabby Tabby and White Tan Tan and Black Tan and White Tortie Tortie and White Tricolour Various White White and Black White and Brindle White and Brown White and Grey White and Liver White and Tabby White and Tan White and Torti Yellow and Grey
Cat Est. Date of Birth *
Weight of cat *
Owner Surrender or Stray? *	Surrender Stray
Are you the original owner? *	NoYes
How long have you had the cat? If the cat has moved from home to home, please describe. *
Reason for giving up the cat. *
Reason Category *	OS - Allergies OS - Biting OS - Illness/Death OS - Marriage/Relationship split OS - Moving OS - Unable to Afford OS - Unable to Cope (Behaviors) OS - Unsuitable Accommodation Stray/Abandoned
Your Veterinarian (Name and Phone Number) *
Are the records at the Vet Clinic in your name or someone else’s?	Mine Someone else
Please give the FIRST & LAST Name of the person the records are under at the vet clinic. *
Has the cat received any shots? If so, we need copies emailed to us *
Does the cat receive any flea/tick medicine? If so, what brand and when? *
Is the dog tattooed or microchipped? *	Unsure Yes No
Spayed or Neutered? *	No Yes Unknown
Has the cat ever been used for breeding? *	Unsure Yes No
Special medications or needs? *
Has the cat ever had a seizure? *	Yes No
Explain your feeding schedule with the cat: brand of food, amount, and how often? *
Where does the cat stay when you are gone? (Free in house, outside, etc.) *
How many hours is the cat left alone? *
Litter box trained? *	Unsure Yes No
Please explain any bad habits the cat may have: *
Special activities or things the cat enjoys? *
Has the cat ever bitten anyone? *	Unsure Yes No
If yes, please give the circumstances. *
Is the cat good with dogs? *	Unsure Yes, but only good with dogs similar in size Yes, good with all dogs No
Is the cat good with other cats? *	Unsure Yes No
Is the cat good with Children? *	Unsure Yes No
What age of child does the cat do best with? *	0-10 11-18 ALL
If not good with children, please explain. *
Is the cat good with men? *	Unsure Yes No
Is the cat good with women? *	Unsure Yes No
Do you take the cat out in public, besides vet appointments? (i.e. walks on leash, in a backpack, carrier, etc) *
How often does this cat get to meet new people either in your home or elsewhere? *
Picture of cat (Required)
Attach vetting images
Staff Only	C (Cat)
The laws of Arkansas will govern the interpretation and enforcement of this contract. I certify that I am the sole owner of said animal(s) described above and that I have the right to surrender animal to The Humane Society of the Ozarks (HSO). I further certify that there are no unpaid veterinary bills or claims on said animal(s). I hereby renounce any and all claims to the above described animal(s). It is my understanding the HSO will do what is best for the animal. With this instrument said animal(s) becomes the property of the HSO. My name and/or phone number may be given to the new owner of this dog, so that the new owner may contact you (previous owner) if they wish to gain more information on this dog. By typing my name below I use that as my electronic signature. *HSO may have you sign this release in person as well.
E-Signature (type full name) *

Check all entries for accuracy, then press the "Submit" button ONLY ONCE. If you do not receive a confirmation email after you hit Submit, please re-submit your application.