Full Address:


Day Phone Number:


Evening Phone Number:




Year of birth:


How would you like to be contacted by (phone, email, or either)?:


Number of animals you are surrendering?:


Species of animal you are surrendering:


Where did you get the animal(s) from (breeder, bred yourself, pet store, friend/family, etc)?:


Animal's name(s)?:


Animal's age(s) or DOB?:


Animal's breed(s)?:


If purebred, will the animal(s) come with papers?:


Animal's color(s)?:


Animal's size(s)?:


Animal's gender(s)?:


Are any of the animal(s) neutered?:


For rabbits, we require owner-surrenders to get the rabbit neutered for $55/neuter. Are you willing to pay to get the animal neutered and transport it as directed?:


Are you willing to pay the medical expenses if the animal is found to have other health issues?:


Animal's personality(ies)? Please be specific:


Is the animal(s) aggressive (biting, thumping, growling, etc)?:


Is the animal(s) litter trained?:


Has the animal been housed inside or outside?:


Wire-cage bottom or a plastic-cage bottom?:


What kind of litter has been used? What brands?:


What kind of diet is the animal being fed? What brands?:


Has the animal(s) had previous health issues or previous litters?:


Does the animal(s) have any current health issues?:


Is the animal good with other species?:


Is the animal bonded to another animal(s) of the same species?:


Is the animal currently in your care?:


Is the animal currently in any danger (abuse, neglect, free-roaming, etc)?:


Why are you surrendering? Please be specific:


Are you willing to make a monetary donation along with the animal(s)?:


Are you willing to donate supplies along with the animal(s)?:


Are you willing to transport the animal(s) as directed?:


Are you willing to sign the animal(s) over to the rescue?:


Do you have any questions or comments?:


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