DATE:__________  BREED:__________________  DOG'S NAME_____________________	

OWNER'S NAME:___________________________________  PHONE:__________________	

ADDRESS:__________________________________________________  ZIP___________	

BREEDER:______________________  AKC#:____________  SEX:_____  ALTERED_____	

HOUSEBROKEN:_____  GOOD WITH CATS_____  GOOD WITH DOGS:_____  BARKER:_____

GOOD WITH CHILDREN: Y/N  AGES:_________  DIGS: Y/N  DOG AGGRESSIVE:_______

SHOT RECORD:______________________________________________________________

REASON FOR RELEASE:_______________________________________________________

OTHER COMMENTS:

__________________________________________________________________________

COSTS:

__________________________________________________________________________

DISPOSITION OF DOG: