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Intake Evaluation Application
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1.
Full Name
(Required.)
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2.
Street
(Required.)
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3.
City
(Required.)
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4.
State
(Required.)
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5.
ZIP
(Required.)
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6.
Mobile Phone
(Required.)
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7.
Email
(Required.)
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8.
What do you have to surrender?
(Required.)
Kitten(s)
Cat(s)
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9.
If kitten(s), how old?
(Required.)
Under 4 weeks old
4 to 8 weeks old
2 to 4 months old
4 to 6 months old
6 to 12 months old
N/A - cat is an adult (1+ years old)
10.
How many kittens?
11.
If cat(s), how old?
1 to 3 years
3 to 5 years
5 to 8 years
8 to 10 years
Over 10 years
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12.
How many cats (over 1 year old)?
(Required.)
13.
How many females (if known)?
14.
How many males (if known)?
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15.
How acquired?
(Required.)
Own
Stray
Inherited from family member/friends
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16.
Reason for surrender?
(Required.)
*
17.
What is the temperament of you cat(s)?
(Required.)
Friendly - can pick up and hold
Friendly - cannot pick up or hold
Shy - afraid of new people, but is attached to owner
Unpredictable - may bite or scratch
Feral (wild) - cannot handle - will bite and scratch
Unknown
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18.
Health Issues - please select all that apply
(Required.)
No health issues known
Sneezing
Runny nose or eyes
Diarrhea
Balding - usually ears, face, legs and/or belly
Injury
Other (please specify)
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19.
Current Vetting - Please check all that apply
(Required.)
No known vetting history
Wormed within last 30 days
Flea treated within last 30 days
Rabies vaccination within last 12 months
Annual vaccination within last 12 months
Feline Aids and or Feline Leukemia Tested within last 30 days
Spayed or Neutered
Other (please specify)
20.
Please upload picture(s)
Choose File
No file chosen
