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

   The following questionnaire provides us with information about how your dog has behaved in many different circumstances while he or she was living with you.   Because your dog 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 dog into the best home.

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

   1. I Understand & Agree
10. Dog Owner's Information
12. First Name*
13. Last Name*
15. Street Address*
17. City*
18. State*
19. Zip Code*
21. Phone Number*
22. Email Address*
24. General & Household Information
26. Dog's Name*
27. Dog's Gender*

    1. Male
    2. Female
28. Is She Spayed?*

    1. Yes
    2. No
29. Is He Neutered?*

    1. Yes
    2. No
31. Dog's Age*
32. Dog's Breed*
33. How Long Have You Had This Dog?*
35. Where did you get this dog?*
37. Do you know any information about the dog prior to becoming the owner?*

    1. Yes
    2. No
39. If yes, please tell us what information you know about the dog prior to becoming the owner.*
41. Why are you seeking to give up your dog? (Please be specific)*
43. Has your dog lived with other animals?*

    1. Yes
    2. No
45. What other animals did your dog live with?*
47. What kind of food does your dog eat? (Please be specific)*
48. How much does your dog eat daily?*
50. Including yourself, please list the ages of the people living in your house with the dog.*
52. Do you have a picture of your dog that you can upload for us?*

    1. Yes
    2. No
54. Please upload the picture.*
56. Typical Behaviors
58. Where does your dog usually go to the bathroom (i.e. outside, piddle pads, inside, etc.)? Please be specific.*
60. Does your dog usually have accidents in the house?*

    1. Yes
    2. No
62. If yes, how many times per day?*
64. Where does your dog usually sleep (i.e. outside, in a crate, etc)? Please be specific.*
66. Is your dog left alone without anyone at home during the week?*

    1. Yes
    2. No
68. How many days/hours is your dog left alone without anyone at home during the week? (Hours/Days)*
70. Where does the dog stay when left alone during the week (i.e. crate, garage, outdoors, etc) Please be specific.*
72. When left alone, does your dog usually show any of the following behaviors?*

    Check all that may apply.

    1. Destroy Household Items

    1. Urinate/Deficate

    1. Bark/Cry

    1. None
74. When playing, does your dog typically show any of the following behaviors?*

    Check All That May Apply

    1. Jump
    2. Growl
    3. Bark
    4. Bite Lightly
    5. Bite Hard
    6. None Of The Above
76. What toys does your dog like? (Please be specific)*
78. What games does your dog like? (Please be specific)*
80. Does your dog know any tricks?*

    1. Yes
    2. No
82. What tricks can your dog do? (Please be specific)*
84. Has your dog ever attended obedience training classes?*

    1. Yes
    2. No
86. If yes, who was the trainer?*
88. Has your dog ever been walked on a leash?*

    1. Yes
    2. No
90. Does your dog have problems riding in the car?*

    1. Yes
    2. No
92. If yes, please explain what problems your dog has when riding in a car.*
94. Has your dog ever escaped from your property?*

    1. Yes
    2. No
96. If yes, please explain how your dog escaped?*
98. Does your dog have any "bad habits"?*

    1. Yes
    2. No
100. If yes, please tell us about the "bad habits". (Please be specific)*
102. Agressive Behaviors (Behaviors That Have EVER Happened)
104. PCAS will check Animal Control records to verify that the information you provide is correct.*

     1. I Understand & Agree
106. Is there any report of your dog EVER inflicting a serious bite to a person, such as an attack or bite that required medical attention?*

     1. Yes

     1. No

     1. Don't Know
108. Is your dog aggressive toward any of the following?*

     Check All That May Apply

     1. Men
     2. Women
     3. Children
     4. None Of The Above
110. Please explain the aggressive behavior(s).*
112. Has your dog ever shown aggression in any of the following situations?*

     Check All That May Apply

     1. Aggressive Behavior Over Food?
     2. Aggressive Behavior Over Bones Or Rawhides?
     3. Aggressive Behavior Over Other Toys?
     4. Aggressive Behavior Over Stolen Objects?
     5. Aggressive Behavior When Disturbed While Sleeping?
     6. Agressive Behavior While Being Handled (brushing, touching feet, cutting nails, bathing, ear cleaning, etc)?
     7. Aggressive Behavior When Adult Or Child Reached For The Dog Or Tried To Pick It Up?
     8. None Of The Above
114. Medical History
116. A complete medical history must be provided prior to intake and you may be required to get your dog up to date on vaccines prior to intake.*

     1. I Understand & Agree
118. Has your dog seen a veterinarian annually?*

     1. Yes
     2. No
119. Has your dog EVER seen a veterinarian?*

     1. Yes
     2. No
121. What is your veterinarian's name?*
123. Where was your dog spayed or neutered?*

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

125. Does your dog have to be muzzled at the veterinarian or groomer?*

     1. Yes
     2. No
127. Has your dog had any past or present medical conditions?*

     1. Yes
     2. No
129. If yes, please list the past or present medical conditions.*
131. Is your pet on any medications?*

     1. Yes
     2. No
133. If yes, please specify the medication(s) that your dog is taking.*
135. Disclosures, Notices & Consents
137. 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
139. 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 dog up to date on vaccines prior to intake.*

     1. I Understand & Agree
141. 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
143. 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
145. By providing your electronic signature below, you authorize any veterinarian providing services for your dog to release medical information to PCAS about your dog and for any/all of your animals, past and present.*

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

     1. I Understand & Agree
149. Electronic Signature

     Please Type In Your Full Legal Name.

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


152. 1. Receive an email copy of this form.
153. Email address

     This field is not part of the form submission.

154. Submit

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