LLAR Animal Transfer In form

Name of representative *

Name of representative filling out this form

First Name

Last Name

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Was the animal surrendered to your facility by the owner? *

Yes

No

Potty Trained? *

Yes

No

Unknown

Neutered/Spayed? *

Yes

No

Rabies vaccine: *

Yes

No

Date of vaccination

MM

DD

YYYY

Bordatella vaccine: *

Yes

No

Date of vaccination

MM

DD

YYYY

DAPP Vaccine: *

Yes

No

Date of vaccination

MM

DD

YYYY

Dewormed: *

Yes

No

Date *

MM

DD

YYYY

Date

MM

DD

YYYY

Microchipped: *

Yes

No

History of biting? *

Human

Animal

No history of biting

Good with cats? *

Yes

No

Unknown

Good with small dogs? *

Yes

No

Unknown

Good with large dogs? *

Yes

No

Unknown

Good with chickens or other animals? *

Yes

No

Unknown

Date

Office use only*

MM

DD

YYYY