First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Alt Email

Text/Pager Email

Animal Information:

What type of animal are you surrendering?*
Choose one: Dog Cat

What is the sex of the animal?*
Choose one: Male Female

Is the animal a mix or purebred?*
Choose one: Mix Purebred

Please List Breed Info:

Coat type:

Age:

Pet Name:

Veterinary Information:

Vet Name:

Vet Address:

Vet Phone:

General Animal Information:

Was this pet adopted from ARF-IL?*
Choose one: Yes No

Is the animal spayed/neutered?
Choose one: Yes No

Is the animal micro-chipped?
Choose one: Yes No

If yes, please provide the micro-chip number and brand:

Have you ever given up a animal in the past for any reason?
Choose one: Yes No

If Yes, Please Explain:

Have you put an animal to sleep (euthanized)?
Choose one: Yes No

If Yes, Please Explain:

Any obedience training?
Choose one: Yes No

If Yes, Please Explain:

Is the animal on any medication?
Choose one: Yes No

If Yes, Please Explain:

Is the animal crate trained?
Choose one: Yes No

Is the animal housebroken?
Choose one: Yes No

Does the animal walk well on a leash?
Choose one: Yes No

Is the animal good Dogs?
Choose one: Yes No

Is the animal good with Cats?
Choose one: Yes No

Is the animal good with Kids?
Choose one: Yes No

What amount of exercise does the animal get daily?

Where is the animal during the day while you are at work?

Where is the animal kept at night?

Where is the animal when you are home?

Why are you giving up the animal?

Please list any other information about the animal that would be useful for our foster homes or potential new adoptive families to know. Please list both good and bad things that we should know.

Agreement and Signature

By signing below, I hereby certify that I am the rightful owner/keeper or caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender Form, hereinafter referred to as “the animal.”

I hereby surrender any and all property rights to the animal. I certify that no other person has a right of property to the animal. I also hereby certify that the animal has /has not (select below) bitten or scratched a human or another animal within the past 10 days. I understand that once I relinquish the animal, the animal will not be available to be returned. I further certify that I have read and understand the terms of this Animal Surrender Form.*
Choose one: Has Has Not

Please digitally sign by typing your name and date : *