Cat Surrender Form

Owner Information

Owner(s) Name: *

Address: *

City: *

State: *

Zip: *

Home/Cell Phone: *

Work Phone:

E-Mail Address: *

Cat Information

Animal's Name:

Sex: *

Breed:

Coat color:

Altered:

Age:

How old was the pet when you became owner?

Declawed:

Microchip Number if available:

Surrender Information

Reason: *

Good with kids? *

What ages?

Other cats? *

Dogs? *

Other pets? What kind?

Used to: * Busy HomeQuiet HomeFamilySingle Owner

Kept where? *

Enjoys (check all that apply): ToysGroomingBeing Played WithBeing Left Alone

If bites - whom - how often - do you know why?

Are there other issues we need to be aware of? Please explain:

Litter box trained? *

Have you had this pet into the vet to see if any of these issues were medical related? *

Results were:

Other concerns we should be aware of?

Medical History

Name of veterinarian and clinic:

Address and telephone number:

Please indicate the last date of Rabies vaccine:

Distemper vaccine:

Feluk/FIV tested?

Date of tests and results

Does your pet have any physical impairment(s)? Any unusual medical problems that he/she has been treated for (i.e., allergies, dermatitis, sensitivity to food or medications, etc.)

Please list current medications:

General Personality/Temperament Information

In an effort to place your pet in an environment best suited to its needs, we ask you to complete this questionnaire as completely and accurately as possible.

Please describe your cat's personality.

If your cat slips outdoors, will he/she come back to you when called or coaxed with food or treats?

Has this ever happened to you?

How long ago?

Where does your cat usually sleep at night? *

When is your cat normally fed? *

Where? *

What brand of DRY CAT FOOD does he/she eat and approximate quantity? *

What about wet or canned foods?

What brand and how often?

Quantity of wet food fed?

How does your cat react to grooming? (Including brushing, combing, toenail clipping and bathing). Please describe behavior.

How does your cat react to strangers?

Does your cat prefer a male human over a female human or N/A? *

Was your cat obtained from: *

Name of shelter or cat rescue, if applicable:

The Owner, by submitting this form, hereby states that this cat has not bitten a human or shown unprovoked aggression towards another domestic animal.

I understand that every effort will be made to place my cat into a good home. In surrendering the above described animal to Two Left Paws Animal Sanctuary I relinquish all rights to said animal and realize the final disposition of the animal is at the discretion of this rescue organization.

I also understand that it is requested that I make a minimum donation of $35.00 to Two Left Paws Animal Sanctuary in order to help defray the cost of feeding, boarding, and medical examination/treatment of this relinquished cat.

Donation received (cash preferred) in the amount of: *

I have, to the best of my knowledge, answered all the questions accurately and as completely as possible and have not willfully misrepresented any provided information regarding this relinquished cat. I do hereby surrender to Two Left Paws Animal Sanctuary the cat described herein, for the purpose of adoption.

I also give permission to Two Left Paws Animal Sanctuary to obtain copies of all veterinary records.

I do understand that I relieve Two Left Paws Animal Sanctuary of all liability.

I do hereby state that I have the authority to enter into this agreement as owner(s) or keeper(s) of this cat.

Owner's Name: *

Today's Date: *

Two Left Paws Animal Sanctuary

PO BOX 153

Sheboygan, WI 53082-0153

Phone: 920.331.0100

Web: www.twoleftpaws.org

E-mail: surrender@twoleftpaws.org

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