First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

What is your pet's name?*

For MARS adopted cats only- What is the MARS tag number?

If you did not adopt from MARS where did your cat come from? *

Is the Cat/Kittens currently in your home?*

How long have you had the Cat/Kittens?*

Can you touch, hold, or pickup the Cat/Kitten*

Is this cat from a Dairy or Poultry Farm?

Has this Cct had any known exposure to sick or deceased birds?

Has this cat had any known exposure to sick or deceased cats or any other animals?

Has this cat shown any neurological or respiratory distress

Has this cat been exposed to H5N1?

Is this cat fed a raw pet food diet?

Breed(s) of the pet? Best guess*

Is your pet male or female?*

Age of the pet? (Your best guess if unknown)*

Weight of the pet? (Your best guess if unknown)*

Is your pet spayed or neutered*

Is your pet current on his/her rabies vaccination (This is mandatory for an assessment if we are able to proceed) and when was their last vet visit?*

if known, please include the last date for the feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) tests:*

Please describe any known health issues. (This does not determine acceptance or denial into our adoption program)

Why are you surrendering your pet? Please give details.*

Please describe your cats personality *

Is your cat good with being handled by people:?*

How does your cat interact with other cats or dogs? Describe. *

Does your cat interact with children? Describe.*

Please describe any known behavioral issues. (This does not determine acceptance or denial into our adoption program)*

Is your pet litter box trained?

How many litter-box’s do you have, and how many cats are in the home?*

Does your pet currently live with:
Choose all that apply: Cats Dogs Kids Other

Is your Cat:
Choose all that apply: Declawed Indoor only Indoor/Outdoor

Has your pet bitten in the last 15 days?*

If your pet has bitten in the last 15 days, what were the circumstances?

Any other information that you could provide to help us find an appropriate home for your pet? Please be as detailed as you can.