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2. Owner Information
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Phone Number
15. E-mail*
17. Animal Information
19. Type*

    dog, cat, bird, reptile, etc

20. Breed*
22. Animal Name*
23. Birthdate*

    Approximate age if unknown

25. Gender*

    1. Male
    2. Female
26. Is your pet spayed or neutered?

    1. Yes
    2. No
    3. Unknown
28. If you are surrendering a cat, have they been declawed?
30. Describe you pets coat color, pattern, and hair length.*
32. Approximate weight or size
34. How long have you had your animal?
36. Where did your animal come from?
38. Does your animal have any health issues or require medication?

    Please explain if yes.

40. Do you have a veterinarian?

    If yes, please list veterinarian and/or clinic name

42. When was the last time your animal was at the veterinarian?
44. What vaccines if any is your animal current on?

    1. Rabies
    2. Distemper
    3. Parvo
    4. Bordetella
    5. Flea and Tick
    6. Heartworm Medication
46. Is your pet microchipped?
48. Is your animal:

    1. Indoor
    2. Outdoor
    3. Both Indoor and Outdoor
50. Is your animal housetrained?
51. Is your animal crate trained
53. Living Environment and Housing

    Please describe what kind of housing or kenneling your animal stays in or lives. For example, what kind of kennel, dog house, small pet enclosure, fencing, etc.

55. When you are not home, where does the animal stay
57. Does your animal have separation anxiety?*
59. Does your animal have food aggression or resource guards?*

    If yes, please explain.

61. How does your animal get along with other animals including but not limited to cats, dogs, small mammals, or livestock*
63. How does your animal get along with adults, children, strangers, etc.*
65. Has your animal ever bitten a person or another animal?*

    If yes, please explain.

67. Has your animal ever growled or lunged at a person or another animal?*

    If yes, please explain

69. What is your reason for surrendering your animal?*
71. If you are located outside Story County, Iowa, what other shelters or rescues have you contacted?
73. If the reason for surrendering your animal is medical related, what steps have taken to address this if any?
75. If the reason for surrendering your animal is behavior/temperament related, what steps have you taken to address this?
77. Please provide any additional information your would like to share with shelter staff pertaining to this application.
79. Please attach any photos of your animal.
81. Please attach any relevant medical records if possible
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82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field