DOG OR OTHER ANIMAL (rabbit, bird, etc.) PROFILE

About You
Name:
Profile Form Date	Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 , Year 20002001200220032004200520062007200820092010
Home Phone:
Work Phone:
Cell Phone:
Work Extension:
Address:
City:
State:
Zip:
Email:
Can you keep the pet until it is adopted?	Yes No
About the Pet
Pet Name:
Pet Gender	Male Female
Pet Species:	Select pet species Cat Dog Other (enter below)
Pet Species (if other):
Pet Breed:
Weight (pounds):
Age:
Reason you are giving up the pet:
Medical Information
Vet Name:
Vet Phone:
Vet Ext:
Is the pet spayed or neutered?
When are the next shots due?
When is the rabies shot due?
Does the pet have any old injuries or health problems?	Yes No
If yes, please describe:
Does the pet need any medication or special diet?:	Yes No
If yes, please describe:
When was the pet usually fed:	AM PM Free Fed Other (please describe below)
Living Environment
Pet Time With You:
Where Acquired:
Where Allowed:	Inside House Car Patio/Deck Fenced Yard Unfenced Yard
How much of the time was the pet outside?
How much of the time was the pet inside?
Where did you leave the pet when you were gone?
Where did you leave the pet when you were gone on holiday/vacation?
Hours Unsupervised:
Where does the pet usually sleep?	In owner's room In owner's bed Doghouse Garage Other (please describe below)
Is this pet a fence jumper?	Yes No
If yes, how high is the fence?
If yes, of what material is the fence made?
Does the pet repeatedly escape from your yard (dogs)?	Yes No
If yes, please describe:
If yes, when does the pet try to escape?	All the time When left alone Other (please describe below)
Training Type:	Obedience Training Home Profesional None
Does the pet know how to:	Sit Stay Lie down Come
Does the pet do any tricks?
Is the pet house trained?	Yes No
House training comments:
If not house trained, has the pet been seen by a vet to rule out physical issues?	Yes No
Has Accidents:	Once a day Once a week Never Every time the pet is inside
Is the pet crate trained?	Yes No
(Dogs) Is the pet leash trained?	Yes No
(Dogs) Lunges Dogs When Leashed?	Yes No
(Dogs) Lunges People When Leashed?	Yes No
(Dogs) Lunges To Play?	Yes No
Behavior
Has the pet ever bitten, snapped or growled?	Yes No
If yes, please describe:
Bad Habits:	Yes No
If yes, please describe:
If yes, what have you done to correct it?
Is Barker:	Yes No
Barks When:
Frightened by anything?	Yes No
Frightened by:	Men Children Brooms Thunder Fireworks Large Trucks Vacuums Water Applicances Hands Feet Other (please describe below)
Frightened Other:
Aggressive Towards Anything?
Aggressive Towards:	Men Women Children Wildlife Male Dogs Female Dogs Cats
Gets Along With:	Dogs (Male) Dogs (Female) Cats (Indoor) Cats (Outdoor) Birds Poultry/Livestock
Get Along Desc:
Good With Children:
Good With Children Desc:
Is Overprotective:	Yes No
Has Favorite Toys:	Yes No
If yes, please describe:
Best Situation:
Administrative Use
EAPL Tag Number:
EAPL Representative Comments:
EAPL Representative Who talked to you:

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