EASEL Surrender Form

First Name *
Last Name *
Email Address *
Veterinarian Name
Cell Phone *
Home Telephone
Street Address *
City *
State *
Zip Code *
Special Assistance	Food Stamps SSI ADC Welfare Medicaid Other
How did you hear of us? *
Animal Name *
Description & Age of Animal *
Size of Animal *
Animal Type *	Bird Cat Dog Ferret Guinea Pig Hamster Mouse Rabbit Rat Snake Tortoise
Breed * For Cats: DSH/Calico etc. For Dogs: Breed of animal	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 Creme DArgent Crossbreed 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 Labrador Retriever Lakeland Terrier Lancashire Heeler Leonberger Lhasa Apso Lilac Lizard Llama Lop Eared Lory/Lorikeet Lovebird Lowchen 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
Coloring/Markings	Amber Beige Beige Light Black Black and Brindle Black and Brown Black and Grey Black and Tan Black and White Black Tortie Blue Blue Tortie Brindle Brindle and Black Brindle and White Brindle Dark Brindle Grey Brindle Light Brown Brown and Black Brown and White Buff Calico Chocolate Chocolate Tortie Cinnamon Cinnamon Tortoiseshell Cream Dark Tabby Dark Tabby and White Diluted Calico Fawn Fawn Tortoiseshell Ginger Ginger and White Golden Green Grey Grey and White Light Amber Lilac Lilac Tortie Liver and White Merle Dark Merle Light Orange Orange and White Orange Tabby Orange Tabby and White Red Ruddy Seal Silver Sorrel Sorrel Tortoiseshell Tabby Tabby and White Tabby Brown Tabby Grey Tabico Tan Tan and Black Tan and White Tiger Tiger and White Tortie Tortie and White Tricolour Tuxedo Various White White and Black White and Brindle White and Brown White and Ginger White and Grey White and Liver White and Tabby White and Tan White and Torti Yellow and Grey
Gender	M F Unknown
Spayed or Neutered? *	NoYes
Reason for Surrender *
	Good with Children
	Well Behaved
	Leash Trained
	Good with Dogs
	Good with Cats
	Good WatchDog
	Digs in Yard
	Barking Excessively
	Tries to Escape
	Destructive
	Separation Anxiety
Owner Signature	Clear
	High Energy
EASEL Representative	KC/MP/GA/MW/OO
Today's Date
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Thank you for submitting your form. You will be contacted by EASEL when we have room for your pet.