PVCHS Owner Surrender Form

Date *
Reason for surrender: *
Description of Animal
Name *
Does you pet know their name?	NoYes
Age Group *	- Baby Young Adult Senior
Actual/Estimated Age
Species *	Bird Cat Chicken Chinchilla Cockatiel Dog Donkey Dove Ferret Gerbil Goat Goldfish Goose Guinea Pig Hamster Hedgehog Horse Llama Mouse Owl Pig Pony Rabbit Rat Snake Tortoise
Sex *	- Male Female
Spayed/Neutered *	- Yes No Unknown
Breed *	Affenpinscher Afghan Hound Airedale Terrier Akbash Akita Alaskan Malamute American Bulldog American Bully American Curl American Eskimo Dog American Polydactyl American Shorthair American Staffordshire Terrier American Water Spaniel American Wirehair Anatolian Shepherd Australian Cattle Dog/Blue Heeler Australian Kelpie Australian Shepherd Australian Terrier Basenji Basset Hound Beagle Bearded Collie Beauceron Bedlington Terrier Belgian Shepherd Dog Sheepdog Belgian Shepherd Laekenois Belgian Shepherd Malinois Belgian Shepherd Tervuren Bengal Bernese Mountain Dog Bichon Frise Birman Black and Tan Coonhound Black Labrador Retriever Black Mouth Cur Bloodhound Bluetick Coonhound Bobtail Bombay Border Collie Border Terrier Boston Terrier Bouvier des Flanders Boxer Boykin Spaniel Briard British Shorthair Brittany Spaniel Brussels Griffon Bullmastiff Bull Terrier Burmese Burmilla Cairn Terrier Calico Canaan Dog Canadian Hairless Canary Cane Corso Mastiff Catahoula Leopard Dog Cattle Dog Cavalier King Charles Spaniel Chartreux Chesapeake Bay Retriever Chihuahua Chinchilla Chinese Crested Dog Chocolate Labrador Retriever Chow Chow Cocker Spaniel Collie Conure Coonhound Corgi Coton de Tulear Crossbreed Cymric Dachshund Dalmatian Dandi Dinmont Terrier Doberman Pinscher Dogo Argentino Dogue de Bordeaux Domestic Long Hair Domestic Medium Hair Domestic Short Hair Dutch Shepherd English Bulldog English Cocker Spaniel English Coonhound English Pointer English Setter English Shepherd English Spot English Springer Spaniel English Toy Spaniel Eskimo Dog Exotic Shorthair Ferret Field Spaniel Fila Brasileiro Finnish Lapphund Finnish Spitz Flat-coated Retriever Foxhound Fox Terrier French Bulldog Gecko Gerbil German Pinscher German Shepherd Dog German Shorthaired Pointer German Spitz German Wirehaired Pointer Glen of Imaal Terrier Golden Retriever Gordon Setter Great Dane Greater Swiss Mountain Dog Great Pyrenees Greyhound Guinea fowl Guinea Pig Hamster Havana Havanese Hedgehog Himalayan Hound Husky Iguana Irish Setter Irish Terrier Irish Water Spaniel Irish Wolfhound Italian Greyhound Italian Spinone Jack Russell Terrier Japanese Bobtail Japanese Chin Javanese Karelian Bear Dog Keeshond Kelpie Kerry Blue Terrier Komondor Kuvasz Labrador Retriever Lakeland Terrier Leonberger Lhasa Apso Lowchen Maine Coon Maltese Manchester Terrier Manx Mastiff Miniature Pinscher Miniature Shnauzer Mixed Breed Mountain Cur Munchkin Neapolitan Mastiff Newfoundland Dog Norfolk Terrier Norwegian Elkhound Norwich Terrier Ocicat Old English Sheepdog Oriental Long Hair Oriental Short Hair Oriental Tabby Papillon Patterdale Terrier (Fell Terrier) Pekingese Persian Petit Basset Griffon Vendeen Pharaoh Hound Pit Bull Terrier Plott Hound Pointer Pomeranian Poodle Pot Bellied Pug Ragamuffin Ragdoll Rat Rat Terrier Redbone Coonhound Red Healer Retriever Rhodesian Ridgeback Rottweiler Russian Blue Saint Bernard St. Bernard Samoyed Schipperke Schnauzer Scottish Deerhound Scottish Fold Scottish Terrier Scottie Sealyham Terrier Selkirk Rex Setter Shar Pei Shepherd Shetland Sheepdog Sheltie Shiba Inu Shih Tzu Siamese Siberian Siberian Husky Silky Terrier Skye Terrier Smooth Fox Terrier Somali Spaniel Sphynx (hairless cat) Spitz Staffordshire Bull Terrier Sugar Glider Terrier Tibetan Mastiff Tibetan Spaniel Tibetan Terrier Tonkinese Tosa Inu Toy Fox Terrier Treeing Walker Coonhound Turkish Angora Turkish Van Vizsla 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 Yellow Labrador Retriever Yorkshire Terrier Yorkie
Color *	Black Black and Blonde Black and Brindle Black and Brown Black and Grey Black and Red Black and Tan Black and White Black Tortie Blonde Blonde and White Blue Blue Merle Blue Point Siamese Brindle Brindle and White Brown Brown and Black Brown and White Brown Tabby Buff Orange Tabby Calico Chocolate Cream Dark Brown Dilute Calico Dilute Tortie Grey Grey and White Grey Tabby Grey Tort Grey Tortie Lynx Point Merle Orange Orange and White Tabby Orange Tabby Persian Red Red and White Seal Point Snowshoe Tabby Tabby/Calico Tan Tan and White Tortie Tortie/Tabby Tortie w/ White Tricolour White White Tabby White w/Merle Yellow Yellow and Grey Yellow and White
Markings or distinguishing features
Microchipped	NoYes
Which of the following fit your pet? Choose as many as apply.	- good with cats good with dogs good with kids good on a leash good in a fenced in yard likes to be inside likes to be outside housebroken
Is there anything your pet loves? Example, favorite toy, food, likes to be scratched behind the ears, etc.
Is there anything that bothers your pet? Example, scared of thunder, doesn't like belly rubs, not good with men, etc.
Why type of home life does your pet currently have?
What advice would you give to your pet's new adopter?
Owner Name and Address
Title	- Mr Mrs Ms Miss
First name *
Last name *
Address
Zip Code
Home Telephone
Mobile Telephone
Email
Is it ok to give out your details to a potential owner?	NoYes
Comments
I hereby surrender this animal to Parke-Vermillion County Humane Society and by doing so, I relinquish all rights of ownership. I also understand I will not be able to determine its final disposition. I do understand, however, PVCHS does not sell nor send animals for research. I do understand this animal will either be adopted to a new owner, sent to a humane rescue, or humanely euthanized. I further agree that neither PVCHS nor its employees will incur any obligation to me on account of such disposition of said animal. In the event PVCHS does incur any obligation, I agree to indemnify the Society and hold it harmless to any obligation, including attorney fees. I also understand and agree that if I should seek to reclaim this animal, I may have to go through the regular adoption procedure and fees. *	YES NO
Please sign your name to finish this questionnaire after you verify all above information is correct *	Clear