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2. Cat Owner Surrender Intake Application
   1. Please read this application carefully and answer all of the questions.

      The following questionnaire provides us with information about how your cat has behaved in many different circumstances while he or she was living with you.   Because your cat is likely to behave in similar ways in its new home, this information will help us find the most suitable home and effectively counsel the new family.  Your open and honest answers are very necessary and appreciated so that we can successfully place your cat into the best home.

   2. All questions require an answer. You will not be able to submit this form until all questions are answered.
4. I acknowledge that completion of this online application does NOT guarantee acceptance of said animal by PCAS.*

   1. I Understand & Agree
6. Cat Owner's Information
8. First Name*
9. Last Name*
11. Street Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
18. Email Address*
20. General Information
22. Cat's Name*
23. Cat's Gender*

    1. Male
    2. Female
24. Is He Neutered?*

    1. Yes
    2. No
25. Is She Spayed*

    1. Yes
    2. No
27. Is Your Cat:*

    1. Front Declawed
    2. Front & Rear Declawed
    3. Not Declawed
28. Cat's Age:*
29. Is Your Cat Micro-Chipped?*

    1. Yes
    2. No
31. How Long Have You Had This Cat?*
32. Where Did You Get This Cat?*
34. Please Tell Us Why You Are Surrendering This Cat:*
36. Do you have a picture of your cat that you can upload for us?*

    1. Yes
    2. No
38. Please Upload The Picture*
40. Household Information
42. Has Your Cat Ever Lived With Other Cat(s)?*

    1. Yes
    2. No
43. How Did Your Cat React To Other Cat(s)?*

    1. Friendly
    2. Bite, Scratch, Hiss
    3. Hide
45. Has Your Cat Lived With Dogs?*

    1. Yes
    2. No
46. How Did Your Cat React To The Dog(s)?*

    1. Friendly
    2. Bite, Scratch, Hiss
    3. Hide
48. Has Your Cat Ever Lived With Children?*

    1. Yes
    2. No
49. How Did Your Cat React To Children?*

    1. Friendly
    2. Bite, Scratch, Hiss
    3. Hide
51. Behavioral Information
53. How Would You Describe You Cat's Behavior?*

    Check all that may apply.

    1. Very Active
    2. Couch Potato
    3. Friendly & Interactive With Family
    4. Friendly With Visitors
    5. Shy With Family

    1. Shy With Visitors
    2. Playful
    3. Affectionate
    4. Independent
55. Is There Any Other Information That You Wish To Tell Us Regarding Your Cat's Personality?*

    1. Yes
    2. No
57. What Do You Want To Share With Us Regarding Your Cat's Personality?*
59. Does Your Cat Have Any Of The Following Behavioral Issues?*

    Check All That May Apply. Please be honest with us as it will let us know what things we should work on with the cat.

    1. Scratch Furniture
    2. Chew Plants
    3. Chew Electric Cords
    4. Jumping On Counters

    1. Spraying
    2. Escaping Outside
    3. Climbing Curtains
61. Has your cat ever shown aggression in any of the following situations?*

    1. Aggressive Behavior Over Food?
    2. Aggressive Behavior Over Toys?
    3. Aggressive Behavior Over Stolen Objects?
    4. Aggressive Behavior When Disturbed While Sleeping?
    5. Agressive Behavior While Being Handled (brushing, touching feet, cutting nails, bathing, ear cleaning, etc)?
    6. Aggressive Behavior When Adult Or Child Reached For The Dog Or Tried To Pick It Up?
    7. None Of The Above

    Check All That May Apply

63. Does Your Cat Elminate Outside Their Litterbox?*

    1. Yes

    1. No
65. How Often Does Your Cat Eliminate Outside Their Litter Box?*
67. How Many Litter Boxes Does Your Cat Have Access To?*
69. Likes And Dislikes
71. What Type Of Food Does Your Cat Eat?*
73. Does Your Cat Enjoy Any Of The Following?*

    Check All That May Apply

    1. Being Groomed
    2. Being Petted

    1. Being Picked Up
    2. Sitting In Your Lap

    1. Being Outside
    2. Other
75. If Other, Please Explain*
77. Does Your Cat Use A Scratching Post?*

    1. Yes
    2. No
78. Does Your Cat Play With Toys?*

    1. Yes
    2. No
80. What Kind Of Littebox Does Your Cat Use?*

    1. Covered
    2. Uncovered
    3. Other
81. If Other, Please Explain*
83. Medical History
85. A complete medical history must be provided prior to intake and you may be required to get your cat up to date on vaccines prior to intake.*

    1. I Understand & Agree
87. Has Your Cat Seen A Veterinarian Annually?*

    1. Yes
    2. No
88. Has Your Cat EVER Seen A Veterinarian?*

    1. Yes
    2. No
90. What Is Your Veterinarian's Name?*
92. Where Was Your Cat Spayed Or Neutered?*

    If you do not know where your cat was spayed or neutered, please enter "Unknown".

94. Does Your Cat Have To Be Sedated At The Veterinarian Or Groomer?*

    1. Yes

    1. No
96. Please List Any Past Or Present Medical Conditions:*
98. Is Your Cat On Any Medications?*

    1. Yes

    1. No
100. If Yes, Please List The Medications That Your Cat Is Taking.*
102. Disclosures, Notices & Consents
104. By providing your electronic signature below, you understand and agree that the completion and submission of this online application does NOT guarantee acceptance of said animal by PCAS.*

     1. I Understand & Agree
106. By providing your electronic signature below, you understand and agree that a complete medical history must be provided prior to intake and you may be required to get your cat up to date on vaccines prior to intake.*

     1. I Understand & Agree
108. By providing your electronic signature below, you certify that the information provided in this application is accurate and truthful to the best of your knowledge.*

     1. I Understand & Agree
110. By Providing Your Electronic Signature Below, You Give Permission For The Porter County Animal Shelter To Investigate And Confirm The Information Provided. You Further Agree that This Information Can Be Shared With Other Humane Societies Or Rescue Groups.*

     1. I Understand & Agree
112. By providing your electronic signature below, you authorize any veterinarian providing services for your cat to release medical information to PCAS about your cat and for any/all of your animals, past and present.*

     1. I Understand & Agree
114. By providing your electronic signature below, you certify that you are the current and legal owner of the cat referenced in this application.*

     1. I Understand & Agree
116. Electronic Signature*

     Please Type In Your Full Legal Name

117. Date Electronically Signed*
     Date Electronically Signed
Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit

* indicates a required field