5194 N. Lake Mtn. Rd. Eagle Mountain, UT 84005

Friends In Need

5194 N. Lake Mtn. Rd. Eagle Mountain, UT 84005

(801) 891-2662

www://www.friends-in-need.org

AUTHORIZATION TO PLACE COMPANION ANIMAL

I hereby authorize Friends In Need (FIN) to place my companion animal named below for adoption:

_____ I agree to keep my companion animal in my possession until a new adoptive family can be found.

_____ I agree to place my companion animal with FIN and relinquish my ownership.

Owner Information

Companion Animal Owner Name ______

Mailing Address ______

Street Address (if different) ______

City ______State ______Zip ______

Phone Numbers Home ______Cell ______Work ______

Email Address ______

Drivers License Number ______State ______

Would you like to make a Relinquish Donation? ______Check ______Cash ______

Companion Animal Information

Animal Name ______Breed______Age _____ Weight______

Please check all that apply: Dog ______Cat ______Male ______Female ______

Spayed ______Neutered ______Declawed ______Micro chipped _____

Veterinarian ______

Last Vaccinated ______Rabies _____ DHPPC _____ Bordetella ____ FVRCPC____ FelV _____

Do you have veterinarian records/vaccination certificates? Yes _____ No ______If yes please attach copies

Medical issues? yes _____ no ____ Explain______

On medications? yes ____ no ____ Explain ______

On special diet? yes _____ no ____ Explain ______

Reaction to dogs? ______

Reaction to cats? ______

Reaction to people? (small children, older children, men, women) ______

______

Any preference for men, women or children? ______

Reaction to being brushed? ______

Reaction to being handled? ______

Food aggression? yes _____ no _____ Explain ______

House trained? yes _____ no _____ Behavior in a vehicle?______

Questions about your dog:

Has your dog bitten anybody? No ____ If yes, please explain ______

______

Does your dog know any tricks? ______

Does your dog like to fetch (sticks, balls etc.)? yes _____ no _____

Can your dog jump fences? yes _____ no ______If yes, how high? ______

Does your dog dig under fences? yes _____ no ______

Obedience, please check all that apply:

Walks on lead nicely ______Sits on command _____ Stays on command _____ Comes on command ____

Pulls on lead _____ Barks a little ______Barks a lot _____Jumps on people _____ Is an escape artist _____

Supplies to be relinquished with your companion animal ______

______

Anything else we should know about your companion animal? ______

______

______

______

By signing this authorization, I understand that any potential adoption must be handled by a FIN representative and the appropriate adoption forms completed, signed and adoption fees paid according to FIN procedures. I will not release the animal to any person without working through FIN. I have also answered all of these questions accurately and to the best of my ability.

Companion Animal Owner Signature ______Date ______

FIN Representative Signature ______Date ______

FIN Notes ______

______

______

______

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06/2010