Federated States of Micronesia
U.S. Virgin Islands
Type of animal Cat Dog
Age of animal when you acquired animal
Where you acquired animal from
Is animal spayed or neutered? * Yes No
What food is the animal eating?
What vet clinic(s) have seen this animal?
Vet clinic phone number(s)
Vet clinic address
Is animal current on vaccinations? Please explain.
Does this animal have any health problems? * Yes No
If animal has health problems, explain.
Is this animal on medication? * Yes No
If on medication, explain.
Is this dog housebroken? If cat is it litter-box trained?
How many hours a day on average is the animal home alone?
Is this animal * inside outside both
How is the animal contained if left alone?
If an outdoor animal is the animal
fenced chained free roam other
When off leash/free roaming will this animal run away?
Would you consider this animal Shy Aloof Friendly Stubborn Dominant Fearful Submissive
Please explain if there are any issues with how this animal relates to men, women, other animals, wildlife, children and strangers.
Have any of the following been an issue: Over-activity Barking Chasing Scratching Aggression Digging Inappropriate scratching/chewing Counter jumping Separation Anxiety Food Aggression Possession Aggression Climbing/Jumping Fences Digging in trash Chasing cars Jumping on people Urine Marking Other
If you marked other, please explain here:
Has this animal ever bitten anyone? * Yes No
If the animal has bitten, please explain the situation:
Is your animal good with cats? Explain.
Is your animal good with kids? Please explain.
If a cat, is the cat declawed? Yes No
Why do you have to surrender this animal at this time?
You agree that you, your spouse and/or co-owners, if any, are irrevocably transferring and surrendering to us legal ownership of the dog or cat on the date of surrender. This gives us complete authority to take whatever actions in our sole judgment are necessary and in the best interest of the animal. You cannot arrange a private adoption for this animal; all potential adopters must go through the HSNEI adoption application process and be approved as a suitable home. HSNEI will work to place your animal into a good home. * Agree Disagree
In an attempt to find a good lifetime home, HSNEI works with other rescue groups, and may in the best interest of the animal place him/her with them. While HSNEI works with every animal to find its ideal living situation, some animals are or become un-adoptable because of severe behavioral issues (i.e. aggression), terminal illness, or for other reasons. If this animal is not adoptable for one of these reasons and a lifetime foster is not available, HSNEI may have to euthanize this animal. * Agree Disagree
By checking agree you surrender all claims and/or rights to the animal/s listed on this form and give HSNEI authorization to make judgments regarding this/these animal(s) well being. * Agree Disagree
I understand that surrendering my animal to HSNEI means if not already done, the organization will pay to have the animal altered and brought up-to-date on vaccinations and other vet work. This typically can cost HSNEI $200 or more to ready the animal for adoption. Do you wish to help defray these costs to find your animal a good home? If yes, the suggested donation is at least $50, but what you can afford is appreciated. * Yes, I am sending my donation to 2345 Millennium Road, Decorah, IA 52101 or will hand it to the person I surrender the animal to. Yes, I understand but will not make a donation. No, I do not understand and will not be surrendering my animal to HSNEI.
How did you learn about HSNEI?