Animal Surrender Form

First Name *

Last Name *

Address *

County *

City *

State *

Zip Code *

Home Phone Number *

Cell Phone Number *

Email *

Pet's Name *

Cat or Dog *

If cat, is it declawed? *

Breed *

Age of Pet *

Gender of Pet *

What Color(s) are your pet? *

Size or Weight of Pet *

Microchip Number *

Where did you get your pet? *

What is the reason for the Surrender? *

Who was your Veterinarian you took your pet? *

You agree to bring your pet's Medical Records *

Is your animal Spayed or Neutered? *

Is your animal on flea/tick and heartworm preventatives? *

Does your animal have any health concerns? *

Is your animal on a special diet? *

Does your animal tolerate having their nails trimmed? *

Is your pet housebroken? *

Where is your pet kept when your are not home? *

Is this an indoor or outdoor pet? *

What commands or tricks does your pet know? *

Does your pet have any likes or dislikes that you want the new owner to know? *

Does your pet live with other animals? *

How does your pet do with dogs? *

How does your pet do with cats? *

How does your pet do with children? *

Has your pet shown any signs of aggression? *

Has your pet ever bit a child or adult? *

If yes, how many times and what were the circumstances? *

Please upload an image or two of your animal that you would like to surrender to us for approval *

I hereby affirm that the above information is true, accurate and complete to the best of my knowledge. If any of this information is untrue, I agree to pick up my animal from the Community Humane Shelter of Steuben County within 2 business days. I understand there is no guarantee that the Community Humane Shelter of Steuben County will take my pet. I agree to pay a non-refundable $50 surrender fee. *