2. Owner Name (First, Last):*
4. Current Street Address (proof of residency must be shown, if the address entered here does not match driver license or other form of approved valid identification surrender request may be denied as we only serve Cedar Hill, DeSoto, and Duncanville)*
6. Phone Number:*
8. Email Address:*
10. Reason for pet surrender (please provide detailed information)*
12. Have you tried looking into help for the reason of surrender?*

    1. Yes
    2. No
    3. I request additional assistance on keeping my pet and would like Tri-City to contact me for more options
14. Please fill out the following in as much detail as possible. Accurate and detailed information can help us make the best match possible between your pet and family or rescue group.
16. Pet's Name:*
18. Breed (If unsure use one of the common breeds listed: Domestic Short/ Medium/ Long Hair):*
20. Pet's gender:*

    1. Male
    2. Female
22. Pet's age (use your best estimate)*
24. Is your pet fixed (sterilized/ altered)?*

    1. Yes
    2. No
    3. Unsure
26. If your pet has been fixed (sterilized/ altered), which clinic?
28. Where did you get your pet?*

    1. This shelter
    2. Another shelter
    3. Breeder
    4. Pet shop
    5. Friend/ Relative
    6. Found/ Stray
    7. Born at home
    8. Rescue group
30. If you received your pet from another shelter or rescue group, what is the name of the group or shelter?
32. How long have you had your pet?*
34. [spacer]
36. Please check all that apply that describes your cat's behavior:*

    1. Friendly
    2. Timid
    3. Outgoing
    4. Needy
    5. Submissive
    6. Calm
    7. High Energy
    8. Playful
    9. Affectionate
    10. Lap Kitty
    11. Mischevious
    12. Slow to adjust
    13. Talks/ Vocal
    14. Other
38. If other, please explain:
40. Where does your pet stay the majority of it's time?*

    1. Inside house
    2. Outside house
    3. Both
    4. Other
42. If other, please explain
44. How many hours is the cat kept outside?*
46. How many hours is the cat kept inside?*
48. Where do you leave the pet when no one is home?*
50. How many hours a day does the cat spend unsupervised? *
52. How does your pet react to that time alone? *
54. Where does the pet sleep?*

    1. Owner's room
    2. Free roam of house
    3. Garage
    4. Other
56. If other, where?
58. What age group has the pet lived with? Select all that apply.*

    1. Adult Men
    2. Adult Women
    3. Seniors
    4. Children under 10
    5. Children under 16
60. How would you describe your pet around children? Check all that apply.*

    1. Friendly
    2. Playful
    3. Tolerant
    4. Afraid
    5. Too much for small children
    6. Never been with children
    7. Other
62. If other, please explain:
64. How does your pet react to strangers? Check all that apply.*

    1. Anxious
    2. Fine
    3. Other
66. If other, please explain.
68. Does the cat use the litter box?*

    1. Yes
    2. No
    3. Outside use
70. If yes, what kind of litter do you use?*

    1. Clumping
    2. Non-Clumping
    3. Pellets
    4. Outside use
    5. Other
72. If other, explain:
74. If no, has the cat been examined to rule out any physical problems?*

    1. Yes
    2. No
    3. Outside use
76. How often does the cat have accidents in the house?*

    1. Once a day
    2. Once a week
    3. Never
    4. All the time
78. If yes, where:
80. Does your pet have any fears? Check all that apply.*

    1. Being alone
    2. Thunderstorms
    3. Men
    4. Women
    5. Children
    6. Loud noises
    7. Hands
    8. Feet
    9. Large vehicles
    10. Appliances
    11. None
    12. Other
82. If other, please explain:
84. Does your pet have any negative behaviors? Check all that apply.*

    1. Chews objects
    2. Bites - Mouthy
    3. Sits on countertops
    4. Darts out the door
    5. None
    6. Other
86. If other, please explain:
88. Does your pet have any positive behaviors? Check all that apply.*

    1. House trained
    2. Rides in cars well
    3. Leash trained
    4. Crate trained
    5. Obedience trained
    6. None
    7. Other
90. If other, please explain:
92. Does this cat use a scratching post?*

    1. Yes
    2. No
94. Has this cat scratched on furniture?*

    1. Yes
    2. No
96. Does your pet escape?*

    1. Yes
    2. No
98. If so, how? *
100. Has your pet been with other animals? *

     1. Yes
     2. No
102. Does your pet prefer to be the only cat?*

     1. Yes
     2. No
     3. Sometimes
104. Does the cat get along with other animals such as? Check all that apply.*

     1. Birds
     2. Dogs (male)
     3. Dogs (female)
     4. Cats (indoor)
     5. Cats (outdoor)
     6. Poultry/ Livestock
     7. None
     8. Other
106. If other, please explain:
108. What types of animals does the cat not get along with? *
110. Has your pet shown any signs of aggression? Check all that apply.*

     1. Growls
     2. Hissing
     3. Strikes out
     4. Biting
     5. None
     6. Other
112. If other, please explain:
114. If pet has shown signs of aggression, what was the reason?
116. For any negative or aggressive behavior have you attempted training or had the cat examined?

     1. Yes
     2. No
118. Has your cat ever bitten someone?*

     1. Yes
     2. No
120. If yes, explain:
122. Does your pet enjoy being groomed?*

     1. Yes
     2. No
     3. Has never been groomed
124. Does your pet tolerate having his/her nails clipped? *

     1. Yes
     2. No
     3. Has never had nails clipped
126. Does your pet have any likes?*
128. Does your pet have any dislikes?*
130. Does your pet have any special needs?
132. Health Info [spacer]
134. Does your pet have any old injuries or health problems? If yes, please explain.*
136. Does your pet have any current health problems? If yes, please explain.*
138. Is your pet currently on medications? If yes, please list the medications.*
140. Has your pet had flea prevention medication within the past 30 days?*

     1. Yes
     2. No
142. What type/brand of food does your pet eat? *
144. When was the cat usually fed?*

     1. AM
     2. PM
     3. Free fed
146. How much kibble is the cat usually fed at a feeding?
148. Any other information you’d like to provide?
150. Do you own any other animals? Check all that apply.*

     1. Dog(s)
     2. Cat(s)
     3. Other
     4. None
152. Veterinarian name or clinic name
154. Date of last visit/ shots
Leave This Blank:


155. Submit

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