Animal Relinquishment Request Form
Please take the time to fill out this form as completely as possible. The information provided will help us to give the best care to your pet and look to find the most suitable home for them.
Owner Information
Pet Guardian's Full Name
*
First Name
Last Name
Email Address
*
Enter 'NONE' if no email
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
*
Phone
Email
Street Address
*
City
*
State
*
Zip Code
*
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Animal Information
Type of Pets You Are Wishing to Relinquish
*
Dog(s)
Cat(s)
Dog(s) and Cat(s)
How many dogs are you relinquishing? (if more than 4, please use this form for the first 4 and then another form for the remaining dogs)
Please Select
1
2
3
4
How many cats are you relinquishing? (if more than 4, please use this form for the first 4 and then another form for the remaining dogs)
Please Select
1
2
3
4
Issue(s) You Are Facing (check off all that apply)
*
Behavior concerns
Financial challenges
Personal health issues
Housing issues
Time commitment
Other (please describe)
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Information for Dog 1
Detailed Dog and Household Information
Please answer these questions for each specific animal
Dog's name
Sex
Male
Female
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
How long have you had this dog? (please indicate years/months)
Has this dog been spayed/neutered?
Yes
No
Don't know
What is your relationship to this dog?
Owner
Friend/Caretaker
Foster owner
Other (please describe)
Where did you get this dog from?
This shelter
Friend/relative
Newspaper/web site
Found as a stray
Breeder
Pet store
Other (please describe/name of other shelter or rescue adopted from)
Reason for giving up this dog
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your dog lived with? (check all that apply)
Has never lived with any other animals
Dogs
Cats
Other (please describe)
Typical Behaviors for Your Dog
Please answer the following questions in this section with how your dog USUALLY behaves
How does your dog usually behave toward the following?
Rows
Never encounter
Friendly
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Men your dog knows
Women your dog knows
Children your dog knows
Unfamiliar men
Unfamiliar women
Unfamiliar children
Dogs your dog knows
Cats your dog knows
Unfamiliar dogs
Unfamiliar cats
Does your dog usually uncontrollably chase or attempt to chase any of the following? (please check all that apply)
Joggers
Bicycles
Skateboarders/roller bladers
Cars/motorcycles
Outdoor cats
Squirrels or other small animals
Birds
Doesn't chase
Other (please describe)
How does your dog usually react when you or another family member does the following to them?
Rows
Never tried
Enjoys
Allows
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Bathes
Brushes
Wipes feet
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? (please check all that apply)
Friendly
Afraid
Barks
Shows teeth/growls
Snaps
Bites
None of these
Do you take your dog out to go to the bathroom?
Yes
No/paper trained
Please specify how many times per day
Does your dog usually have "accidents" in the house?
Yes
No
Please specify how many times per day
Where does your dog spend most of their time?
Inside the house, runs free
Inside the house in a crate/cage
Outside the house, runs free in the neighborhood
Outside the house, runs free in the yard
Outside the house, in a crate/cage
Outside the house, tied
Other (please describe)
How long is your dog left alone, without people, during the week?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
When your dog is left alone, are they...
Outdoors
Free in home
Confined to a room
In a crate/cage
Other (please describe)
When your dog is left alone, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When you are home, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When your dog plays, do they typically.... (please check all that apply)
Jump
Growl
Bark
Bite lightly
Bite hard
None of these
What toys does your dog like? (please check all that apply)
Balls
Frisbee
Plush
Squeaky
Tug toy
None
Other (please describe)
What games does your dog like? (please check all that apply)
Fetch
Tug
Chase
Wrestling
None
Other (please describe)
Is your dog scared of anything?
Yes
No
Please describe
Please tell us your dog's "bad habits"
Is your dog allowed on furniture
Yes
No
Where does your dog usually sleep overnight?
Crate/cage
Floor
Dog bed
Couch
Owner's bed
Other (please describe)
What commands does your dog know?
No commands known
Sit
Stay
Down
Come
Heel
Give paw
Other (please describe)
Has your dog attended any obedience training classes?
Yes
No
Has your dog ever been walked on a leash?
Yes
No
Does your dog have problems riding in the car?
Yes
No
Don't know
Please describe
Has your dog escaped your property 2 or more times in the last 6 months?
Yes
No
Please describe
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
Yes
No
Don't know
Has your dog ever attacked another dog resulting in severe injury or death to another dog?
Yes
No
Don't know
Has your dog ever attacked another domesticated animal species (cats or livestock but not "small pets" like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal?
Yes
No
Don't know
Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors toward men, women, children, dogs, or other domesticated animal species (cats or livestock, not "small pets" like hamsters, guinea pigs, etc.) Do not include aggressive behaviors directed toward a veterinarian or groomer.
Rows
Shows teeth/growls
Snaps
Bites
None of these
Do not know
Men
Women
Children
Dog
Other domesticated animal species (cat, livestock, etc.)
If a snap or bite to men or women was checked, did the snap or bite to adult take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
If a snap or bite to children was checked, did the snap or bite to a child take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
Please explain the circumstances of the snap or bite. If you checked more than one bite in the table above, please explain the circumstances of every snap or bite.
If any aggressive behavior to men, women, or children was checked in the table above, please check the boxes only if you are answering yes to the following questions.
Rows
Men
Women
Children
Was the aggressive behavior over food?
Was it over bones or rawhides or chews?
Was it over toys?
Was it over stolen objects?
Was it when the dog was disturbed while sleeping or resting?
Was it when an adult or child handled the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. but do NOT include reaction to a vet or groomer)?
Was it when an adult or child entered the house or yard?
Was it when an adult or child approached or reached toward the dog?
Medical History
Does your dog see a veterinarian at least once a year?
Yes
No
Veterinarian Name
Area Code
Phone Number
Email
Check if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer.
Rows
Vet or Groomer has never attempted to perform these on my dog
Shows teeth/growls
Snaps
Bites
Never shown one of these behaviors
Examination (including heart and ears)
Restraint
Administration of shots
Trimming nails
Taking blood
Does your dog have to be muzzled at the veterinarian?
Yes
No
Does your dog have any past or present medical conditions?
Yes
No
Please describe
Is your dog currently on any medication or special diet?
Yes
No
Please describe
What type of food does your dog eat? (please check all that apply)
Dry (kibble)
Wet/canned
Table scraps
Other (please describe)
Please feel free to tell us any additional helpful comments.
Information for Dog 2
Detailed Dog and Household Information
Please answer these questions for each specific animal
Second dog's name
Sex
Male
Female
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
How long have you had this dog? (please indicate years/months)
Has this dog been spayed/neutered?
Yes
No
Don't know
What is your relationship to this dog?
Owner
Friend/Caretaker
Foster owner
Other (please describe)
Where did you get this dog from?
This shelter
Friend/relative
Newspaper/web site
Found as a stray
Breeder
Pet store
Other (please describe/name of other shelter or rescue adopted from)
Reason for giving up this dog
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your dog lived with? (check all that apply)
Has never lived with any other animals
Dogs
Cats
Other (please describe)
Typical Behaviors for Your Dog
Please answer the following questions in this section with how your dog USUALLY behaves
How does your dog usually behave toward the following?
Rows
Never encounter
Friendly
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Men your dog knows
Women your dog knows
Children your dog knows
Unfamiliar men
Unfamiliar women
Unfamiliar children
Dogs your dog knows
Cats your dog knows
Unfamiliar dogs
Unfamiliar cats
Does your dog usually uncontrollably chase or attempt to chase any of the following? (please check all that apply)
Joggers
Bicycles
Skateboarders/roller bladers
Cars/motorcycles
Outdoor cats
Squirrels or other small animals
Birds
Doesn't chase
Other (please describe)
How does your dog usually react when you or another family member does the following to them?
Rows
Never tried
Enjoys
Allows
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Bathes
Brushes
Wipes feet
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? (please check all that apply)
Friendly
Afraid
Barks
Shows teeth/growls
Snaps
Bites
None of these
Do you take your dog out to go to the bathroom?
Yes
No/paper trained
Please specify how many times per day
Does your dog usually have "accidents" in the house?
Yes
No
Please specify how many times per day
Where does your dog spend most of their time?
Inside the house, runs free
Inside the house in a crate/cage
Outside the house, runs free in the neighborhood
Outside the house, runs free in the yard
Outside the house, in a crate/cage
Outside the house, tied
Other (please describe)
How long is your dog left alone, without people, during the week?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
When your dog is left alone, are they...
Outdoors
Free in home
Confined to a room
In a crate/cage
Other (please describe)
When your dog is left alone, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When you are home, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When your dog plays, do they typically.... (please check all that apply)
Jump
Growl
Bark
Bite lightly
Bite hard
None of these
What toys does your dog like? (please check all that apply)
Balls
Frisbee
Plush
Squeaky
Tug toy
None
Other (please describe)
What games does your dog like? (please check all that apply)
Fetch
Tug
Chase
Wrestling
None
Other (please describe)
Is your dog scared of anything?
Yes
No
Please describe
Please tell us your dog's "bad habits"
Is your dog allowed on furniture
Yes
No
Where does your dog usually sleep overnight?
Crate/cage
Floor
Dog bed
Couch
Owner's bed
Other (please describe)
What commands does your dog know?
No commands known
Sit
Stay
Down
Come
Heel
Give paw
Other (please describe)
Has your dog attended any obedience training classes?
Yes
No
Has your dog ever been walked on a leash?
Yes
No
Does your dog have problems riding in the car?
Yes
No
Don't know
Please describe
Has your dog escaped your property 2 or more times in the last 6 months?
Yes
No
Please describe
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
Yes
No
Don't know
Has your dog ever attacked another dog resulting in severe injury or death to another dog?
Yes
No
Don't know
Has your dog ever attacked another domesticated animal species (cats or livestock but not "small pets" like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal?
Yes
No
Don't know
Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors toward men, women, children, dogs, or other domesticated animal species (cats or livestock, not "small pets" like hamsters, guinea pigs, etc.) Do not include aggressive behaviors directed toward a veterinarian or groomer.
Rows
Shows teeth/growls
Snaps
Bites
None of these
Do not know
Men
Women
Children
Dog
Other domesticated animal species (cat, livestock, etc.)
If a snap or bite to men or women was checked, did the snap or bite to adult take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
If a snap or bite to children was checked, did the snap or bite to a child take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
Please explain the circumstances of the snap or bite. If you checked more than one bite in the table above, please explain the circumstances of every snap or bite.
If any aggressive behavior to men, women, or children was checked in the table above, please check the boxes only if you are answering yes to the following questions.
Rows
Men
Women
Children
Was the aggressive behavior over food?
Was it over bones or rawhides or chews?
Was it over toys?
Was it over stolen objects?
Was it when the dog was disturbed while sleeping or resting?
Was it when an adult or child handled the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. but do NOT include reaction to a vet or groomer)?
Was it when an adult or child entered the house or yard?
Was it when an adult or child approached or reached toward the dog?
Medical History
Does your dog see a veterinarian at least once a year?
Yes
No
Veterinarian Name
Area Code
Phone Number
Email
Check if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer.
Rows
Vet or Groomer has never attempted to perform these on my dog
Shows teeth/growls
Snaps
Bites
Never shown one of these behaviors
Examination (including heart and ears)
Restraint
Administration of shots
Trimming nails
Taking blood
Does your dog have to be muzzled at the veterinarian?
Yes
No
Does your dog have any past or present medical conditions?
Yes
No
Please describe
Is your dog currently on any medication or special diet?
Yes
No
Please describe
What type of food does your dog eat? (please check all that apply)
Dry (kibble)
Wet/canned
Table scraps
Other (please describe)
Please feel free to tell us any additional helpful comments.
Information for Dog 3
Detailed Dog and Household Information
Please answer these questions for each specific animal
Third dog's name
Sex
Male
Female
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
How long have you had this dog? (please indicate years/months)
Has this dog been spayed/neutered?
Yes
No
Don't know
What is your relationship to this dog?
Owner
Friend/Caretaker
Foster owner
Other (please describe)
Where did you get this dog from?
This shelter
Friend/relative
Newspaper/web site
Found as a stray
Breeder
Pet store
Other (please describe/name of other shelter or rescue adopted from)
Reason for giving up this dog
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your dog lived with? (check all that apply)
Has never lived with any other animals
Dogs
Cats
Other (please describe)
Typical Behaviors for Your Dog
Please answer the following questions in this section with how your dog USUALLY behaves
How does your dog usually behave toward the following?
Rows
Never encounter
Friendly
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Men your dog knows
Women your dog knows
Children your dog knows
Unfamiliar men
Unfamiliar women
Unfamiliar children
Dogs your dog knows
Cats your dog knows
Unfamiliar dogs
Unfamiliar cats
Does your dog usually uncontrollably chase or attempt to chase any of the following? (please check all that apply)
Joggers
Bicycles
Skateboarders/roller bladers
Cars/motorcycles
Outdoor cats
Squirrels or other small animals
Birds
Doesn't chase
Other (please describe)
How does your dog usually react when you or another family member does the following to them?
Rows
Never tried
Enjoys
Allows
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Bathes
Brushes
Wipes feet
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? (please check all that apply)
Friendly
Afraid
Barks
Shows teeth/growls
Snaps
Bites
None of these
Do you take your dog out to go to the bathroom?
Yes
No/paper trained
Please specify how many times per day
Does your dog usually have "accidents" in the house?
Yes
No
Please specify how many times per day
Where does your dog spend most of their time?
Inside the house, runs free
Inside the house in a crate/cage
Outside the house, runs free in the neighborhood
Outside the house, runs free in the yard
Outside the house, in a crate/cage
Outside the house, tied
Other (please describe)
How long is your dog left alone, without people, during the week?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
When your dog is left alone, are they...
Outdoors
Free in home
Confined to a room
In a crate/cage
Other (please describe)
When your dog is left alone, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When you are home, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When your dog plays, do they typically.... (please check all that apply)
Jump
Growl
Bark
Bite lightly
Bite hard
None of these
What toys does your dog like? (please check all that apply)
Balls
Frisbee
Plush
Squeaky
Tug toy
None
Other (please describe)
What games does your dog like? (please check all that apply)
Fetch
Tug
Chase
Wrestling
None
Other (please describe)
Is your dog scared of anything?
Yes
No
Please describe
Please tell us your dog's "bad habits"
Is your dog allowed on furniture
Yes
No
Where does your dog usually sleep overnight?
Crate/cage
Floor
Dog bed
Couch
Owner's bed
Other (please describe)
What commands does your dog know?
No commands known
Sit
Stay
Down
Come
Heel
Give paw
Other (please describe)
Has your dog attended any obedience training classes?
Yes
No
Has your dog ever been walked on a leash?
Yes
No
Does your dog have problems riding in the car?
Yes
No
Don't know
Please describe
Has your dog escaped your property 2 or more times in the last 6 months?
Yes
No
Please describe
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
Yes
No
Don't know
Has your dog ever attacked another dog resulting in severe injury or death to another dog?
Yes
No
Don't know
Has your dog ever attacked another domesticated animal species (cats or livestock but not "small pets" like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal?
Yes
No
Don't know
Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors toward men, women, children, dogs, or other domesticated animal species (cats or livestock, not "small pets" like hamsters, guinea pigs, etc.) Do not include aggressive behaviors directed toward a veterinarian or groomer.
Rows
Shows teeth/growls
Snaps
Bites
None of these
Do not know
Men
Women
Children
Dog
Other domesticated animal species (cat, livestock, etc.)
If a snap or bite to men or women was checked, did the snap or bite to adult take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
If a snap or bite to children was checked, did the snap or bite to a child take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
Please explain the circumstances of the snap or bite. If you checked more than one bite in the table above, please explain the circumstances of every snap or bite.
If any aggressive behavior to men, women, or children was checked in the table above, please check the boxes only if you are answering yes to the following questions.
Rows
Men
Women
Children
Was the aggressive behavior over food?
Was it over bones or rawhides or chews?
Was it over toys?
Was it over stolen objects?
Was it when the dog was disturbed while sleeping or resting?
Was it when an adult or child handled the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. but do NOT include reaction to a vet or groomer)?
Was it when an adult or child entered the house or yard?
Was it when an adult or child approached or reached toward the dog?
Medical History
Does your dog see a veterinarian at least once a year?
Yes
No
Veterinarian Name
Area Code
Phone Number
Email
Check if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer.
Rows
Vet or Groomer has never attempted to perform these on my dog
Shows teeth/growls
Snaps
Bites
Never shown one of these behaviors
Examination (including heart and ears)
Restraint
Administration of shots
Trimming nails
Taking blood
Does your dog have to be muzzled at the veterinarian?
Yes
No
Does your dog have any past or present medical conditions?
Yes
No
Please describe
Is your dog currently on any medication or special diet?
Yes
No
Please describe
What type of food does your dog eat? (please check all that apply)
Dry (kibble)
Wet/canned
Table scraps
Other (please describe)
Please feel free to tell us any additional helpful comments.
Information for Dog 4
Detailed Dog and Household Information
Please answer these questions for each specific animal
Fourth dog's name
Sex
Male
Female
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
How long have you had this dog? (please indicate years/months)
Has this dog been spayed/neutered?
Yes
No
Don't know
What is your relationship to this dog?
Owner
Friend/Caretaker
Foster owner
Other (please describe)
Where did you get this dog from?
This shelter
Friend/relative
Newspaper/web site
Found as a stray
Breeder
Pet store
Other (please describe/name of other shelter or rescue adopted from)
Reason for giving up this dog
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your dog lived with? (check all that apply)
Has never lived with any other animals
Dogs
Cats
Other (please describe)
Typical Behaviors for Your Dog
Please answer the following questions in this section with how your dog USUALLY behaves
How does your dog usually behave toward the following?
Rows
Never encounter
Friendly
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Men your dog knows
Women your dog knows
Children your dog knows
Unfamiliar men
Unfamiliar women
Unfamiliar children
Dogs your dog knows
Cats your dog knows
Unfamiliar dogs
Unfamiliar cats
Does your dog usually uncontrollably chase or attempt to chase any of the following? (please check all that apply)
Joggers
Bicycles
Skateboarders/roller bladers
Cars/motorcycles
Outdoor cats
Squirrels or other small animals
Birds
Doesn't chase
Other (please describe)
How does your dog usually react when you or another family member does the following to them?
Rows
Never tried
Enjoys
Allows
Afraid
Shows teeth/growls
Snaps
Bites
None of these
Bathes
Brushes
Wipes feet
How does your dog usually react when an unfamiliar person approaches or enters the yard or house? (please check all that apply)
Friendly
Afraid
Barks
Shows teeth/growls
Snaps
Bites
None of these
Do you take your dog out to go to the bathroom?
Yes
No/paper trained
Please specify how many times per day
Does your dog usually have "accidents" in the house?
Yes
No
Please specify how many times per day
Where does your dog spend most of their time?
Inside the house, runs free
Inside the house in a crate/cage
Outside the house, runs free in the neighborhood
Outside the house, runs free in the yard
Outside the house, in a crate/cage
Outside the house, tied
Other (please describe)
How long is your dog left alone, without people, during the week?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hours
When your dog is left alone, are they...
Outdoors
Free in home
Confined to a room
In a crate/cage
Other (please describe)
When your dog is left alone, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When you are home, does your dog usually show any of the following behaviors? (please check all that apply)
Destroys household items
Urinates/defecates
Barks
Cries
None of these
When your dog plays, do they typically.... (please check all that apply)
Jump
Growl
Bark
Bite lightly
Bite hard
None of these
What toys does your dog like? (please check all that apply)
Balls
Frisbee
Plush
Squeaky
Tug toy
None
Other (please describe)
What games does your dog like? (please check all that apply)
Fetch
Tug
Chase
Wrestling
None
Other (please describe)
Is your dog scared of anything?
Yes
No
Please describe
Please tell us your dog's "bad habits"
Is your dog allowed on furniture
Yes
No
Where does your dog usually sleep overnight?
Crate/cage
Floor
Dog bed
Couch
Owner's bed
Other (please describe)
What commands does your dog know?
No commands known
Sit
Stay
Down
Come
Heel
Give paw
Other (please describe)
Has your dog attended any obedience training classes?
Yes
No
Has your dog ever been walked on a leash?
Yes
No
Does your dog have problems riding in the car?
Yes
No
Don't know
Please describe
Has your dog escaped your property 2 or more times in the last 6 months?
Yes
No
Please describe
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Is there any report of your dog ever inflicting a serious bite to a person (such as an attack or a bite requiring hospitalization)?
Yes
No
Don't know
Has your dog ever attacked another dog resulting in severe injury or death to another dog?
Yes
No
Don't know
Has your dog ever attacked another domesticated animal species (cats or livestock but not "small pets" like hamsters, guinea pigs, etc.) resulting in severe injury or death to another domesticated animal?
Yes
No
Don't know
Please check the appropriate box if your dog has ever shown any of the following aggressive behaviors toward men, women, children, dogs, or other domesticated animal species (cats or livestock, not "small pets" like hamsters, guinea pigs, etc.) Do not include aggressive behaviors directed toward a veterinarian or groomer.
Rows
Shows teeth/growls
Snaps
Bites
None of these
Do not know
Men
Women
Children
Dog
Other domesticated animal species (cat, livestock, etc.)
If a snap or bite to men or women was checked, did the snap or bite to adult take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
If a snap or bite to children was checked, did the snap or bite to a child take place while breaking up a dog fight or while your dog was in severe pain?
Yes
No
Please explain the circumstances of the snap or bite. If you checked more than one bite in the table above, please explain the circumstances of every snap or bite.
If any aggressive behavior to men, women, or children was checked in the table above, please check the boxes only if you are answering yes to the following questions.
Rows
Men
Women
Children
Was the aggressive behavior over food?
Was it over bones or rawhides or chews?
Was it over toys?
Was it over stolen objects?
Was it when the dog was disturbed while sleeping or resting?
Was it when an adult or child handled the dog (brushing, handling feet, bathing, teeth brushing, ear cleaning, etc. but do NOT include reaction to a vet or groomer)?
Was it when an adult or child entered the house or yard?
Was it when an adult or child approached or reached toward the dog?
Medical History
Does your dog see a veterinarian at least once a year?
Yes
No
Veterinarian Name
Area Code
Phone Number
Email
Check if your dog has ever shown any of the following aggressive behaviors when handled by a veterinarian or groomer.
Rows
Vet or Groomer has never attempted to perform these on my dog
Shows teeth/growls
Snaps
Bites
Never shown one of these behaviors
Examination (including heart and ears)
Restraint
Administration of shots
Trimming nails
Taking blood
Does your dog have to be muzzled at the veterinarian?
Yes
No
Does your dog have any past or present medical conditions?
Yes
No
Please describe
Is your dog currently on any medication or special diet?
Yes
No
Please describe
What type of food does your dog eat? (please check all that apply)
Dry (kibble)
Wet/canned
Table scraps
Other (please describe)
Please feel free to tell us any additional helpful comments.
Information for Cat 1
Detailed Cat and Household Information
Please answer these questions for each specific animal
Cat's Name
Sex
Male
Female
Unknown
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
Color
How long has this cat lived with you (please indicate years/months)
Is this cat spayed/neutered?
Yes
No
Don't know
How old was your cat when they got spayed/neutered? (please indicate if years or months)
Has this cat been declawed?
Yes
No
Where did you get this cat from?
Chemung County SPCA
Friend/relative
Found as a stray
Other shelter/humane society
Other (please describe)
Why are you surrendering your cat to the shelter? (check all that apply)
Time commitment
Family issues
Health issues (yours or cat)
Financial reasons
Biting/aggression
Litter box issues
Spraying
Scratching furniture
Not getting along with other pets
Not getting along with children
Other (please describe)
Please explain in your own words why you need to relinquish your cat
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your cat lived with? (check all that apply)
Has never lived with other animals
Cats
Dogs
Other (please describe)
How would you describe your household?
Active
Noisy
Average
Quiet
Is there some type of assistance that we may provide that could help you keep your cat, such as help with spay/neuter, behavior counseling, medical assistance, cat food, or support?
Typical Behaviors for Your Cat
Please answer the following questions in this section with how your cat USUALLY behaves
How would you describe your cat's personality? (check all that apply)
Friendly
Shy
Independent
Fearful
Playful
Affectionate
Aloof
Aggressive
Vocal
Describe your cat's personality in your words:
How many hours a day is your cat used to being left alone?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hrs
Where does your cat spend most of their time?
Inside
Outside
Inside/Outside
What does your cat do when they go outside? (check all that apply)
Stays close to the house
Wanders off
Fights with other cats
When inside, where does your cat spend most of their time?
Does your cat like to sit in your lap?
Yes
No
Does your cat like to be petted?
Yes
No
What do they do when they don't want to be petted/have had enough petting?
Does your cat like to be picked up?
Yes
No
What do they do when they don't want to be picked up?
Are there any parts of their body that they don't like touched?
Yes
No
Which body parts do they not like touched? (check all that apply)
Head
Paws
Tail
Stomach
Other (please describe)
Will your cat allow you to trim their nails?
Yes
No
Never tried
How does your cat react to being brushed?
Enjoys
Tolerates
Dislikes
Never tried
How would you describe your cat's behavior around children?
Playful
Calm
Avoids
Shy
Friendly
Tolerant
Dislikes
Outgoing
Never been around children
Would you recommend that this cat be placed with children?
Yes
No
If yes, how old should the children be?
Is your cat afraid of or uncomfortable with any of the following? (check all that apply)
Women
Men
Children
Infants
Strangers
None of the above
What does your cat do when they are uncomfortable?
Runs away
Hides
Hisses
Scratches
Bites
How does your cat interact with other cats?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around other cats
How does your cat interact with dogs?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around dogs
Does your cat spray indoors (territory marking, urine on vertical surfaces)?
Yes
No
What type of litterbox do you have?
Uncovered
Covered
Other (please describe)
How many boxes do you have?
Where are they located?
What type of litter do you use?
Clay
Clumping
Other (please describe)
Does your cat ever eliminate outside the litterbox?
Urinates only
Defecates only
Urinates and defecates outside of the litterbox
Never eliminates outside of the litterbox
How frequently?
Daily
Weekly
Once in awhile
Where do they eliminate if not in the box?
How long has your cat been inappropriately eliminating outside the litterbox?
Did your cat ever receive medical treatment for house soiling?
Yes
No
What have you tried to help the inappropriate elimination?
Does your cat like to play?
Yes
No
What is their favorite game or toy?
Where does your cat sharpen their nails?
Couch/chair
Scratching post
Rug
Other (please describe)
Where does your cat like to sleep?
Couch
Chair
Bed
Cat bed
Other (please describe)
Does your cat do any of the following (check all that apply):
Jump on counters or tables
Climb the curtains
Hiss or bite
Pounce on people
Exhibit fearfulness or shyness
Catch mice or birds
None of the above
What is your cat's best quality?
What is your cat's worst quality?
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Does your cat show aggression towards (check all that apply):
Family members
Visitors
None of the above
How does your cat show aggression (check all that apply):
Hiss
Swat at
Scratch
Bite
What do you do when your cat becomes aggressive?
Medical History
When was the last time your cat was seen by a veterinarian?
Never
3 months ago
6 months ago
Last year
Longer ago than last year
Veterinarian Name
Area Code
Phone Number
Email
Does your cat have any health problems or old injuries
Yes
No
If yes, please describe
Is your cat currently on any medications or a special diet?
Yes
No
If yes, please describe
Please indicate what kind of food your cat currently is given and how often:
Rows
Once daily
Twice daily
Free food
Only occasionally
Never
Dry Food
Canned Food
What is the brand name of the dry food they are given?
What is the brand name of the canned food they are given?
Is there anything else we should know about your cat?
Information for Cat 2
Detailed Cat and Household Information
Please answer these questions for each specific animal
Second Cat's Name
Sex
Male
Female
Unknown
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
Color
How long has this cat lived with you (please indicate years/months)
Is this cat spayed/neutered?
Yes
No
Don't know
How old was your cat when they got spayed/neutered? (please indicate if years or months)
Has this cat been declawed?
Yes
No
Where did you get this cat from?
Chemung County SPCA
Friend/relative
Found as a stray
Other shelter/humane society
Other (please describe)
Why are you surrendering your cat to the shelter? (check all that apply)
Time commitment
Family issues
Health issues (yours or cat)
Financial reasons
Biting/aggression
Litter box issues
Spraying
Scratching furniture
Not getting along with other pets
Not getting along with children
Other (please describe)
Please explain in your own words why you need to relinquish your cat
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your cat lived with? (check all that apply)
Has never lived with other animals
Cats
Dogs
Other (please describe)
How would you describe your household?
Active
Noisy
Average
Quiet
Is there some type of assistance that we may provide that could help you keep your cat, such as help with spay/neuter, behavior counseling, medical assistance, cat food, or support?
Typical Behaviors for Your Cat
Please answer the following questions in this section with how your cat USUALLY behaves
How would you describe your cat's personality? (check all that apply)
Friendly
Shy
Independent
Fearful
Playful
Affectionate
Aloof
Aggressive
Vocal
Describe your cat's personality in your words:
How many hours a day is your cat used to being left alone?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hrs
Where does your cat spend most of their time?
Inside
Outside
Inside/Outside
What does your cat do when they go outside? (check all that apply)
Stays close to the house
Wanders off
Fights with other cats
When inside, where does your cat spend most of their time?
Does your cat like to sit in your lap?
Yes
No
Does your cat like to be petted?
Yes
No
What do they do when they don't want to be petted/have had enough petting?
Does your cat like to be picked up?
Yes
No
What do they do when they don't want to be picked up?
Are there any parts of their body that they don't like touched?
Yes
No
Which body parts do they not like touched? (check all that apply)
Head
Paws
Tail
Stomach
Other (please describe)
Will your cat allow you to trim their nails?
Yes
No
Never tried
How does your cat react to being brushed?
Enjoys
Tolerates
Dislikes
Never tried
How would you describe your cat's behavior around children?
Playful
Calm
Avoids
Shy
Friendly
Tolerant
Dislikes
Outgoing
Never been around children
Would you recommend that this cat be placed with children?
Yes
No
If yes, how old should the children be?
Is your cat afraid of or uncomfortable with any of the following? (check all that apply)
Women
Men
Children
Infants
Strangers
None of the above
What does your cat do when they are uncomfortable?
Runs away
Hides
Hisses
Scratches
Bites
How does your cat interact with other cats?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around other cats
How does your cat interact with dogs?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around dogs
Does your cat spray indoors (territory marking, urine on vertical surfaces)?
Yes
No
What type of litterbox do you have?
Uncovered
Covered
Other (please describe)
How many boxes do you have?
Where are they located?
What type of litter do you use?
Clay
Clumping
Other (please describe)
Does your cat ever eliminate outside the litterbox?
Urinates only
Defecates only
Urinates and defecates outside of the litterbox
Never eliminates outside of the litterbox
How frequently?
Daily
Weekly
Once in awhile
Where do they eliminate if not in the box?
How long has your cat been inappropriately eliminating outside the litterbox?
Did your cat ever receive medical treatment for house soiling?
Yes
No
What have you tried to help the inappropriate elimination?
Does your cat like to play?
Yes
No
What is their favorite game or toy?
Where does your cat sharpen their nails?
Couch/chair
Scratching post
Rug
Other (please describe)
Where does your cat like to sleep?
Couch
Chair
Bed
Cat bed
Other (please describe)
Does your cat do any of the following (check all that apply):
Jump on counters or tables
Climb the curtains
Hiss or bite
Pounce on people
Exhibit fearfulness or shyness
Catch mice or birds
None of the above
What is your cat's best quality?
What is your cat's worst quality?
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Does your cat show aggression towards (check all that apply):
Family members
Visitors
None of the above
How does your cat show aggression (check all that apply):
Hiss
Swat at
Scratch
Bite
What do you do when your cat becomes aggressive?
Medical History
When was the last time your cat was seen by a veterinarian?
Never
3 months ago
6 months ago
Last year
Longer ago than last year
Veterinarian Name
Area Code
Phone Number
Email
Does your cat have any health problems or old injuries
Yes
No
If yes, please describe
Is your cat currently on any medications or a special diet?
Yes
No
If yes, please describe
Please indicate what kind of food your cat currently is given and how often:
Rows
Once daily
Twice daily
Free food
Only occasionally
Never
Dry Food
Canned Food
What is the brand name of the dry food they are given?
What is the brand name of the canned food they are given?
Is there anything else we should know about your cat?
Information for Cat 3
Detailed Cat and Household Information
Please answer these questions for each specific animal
Third Cat's Name
Sex
Male
Female
Unknown
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
Color
How long has this cat lived with you (please indicate years/months)
Is this cat spayed/neutered?
Yes
No
Don't know
How old was your cat when they got spayed/neutered? (please indicate if years or months)
Has this cat been declawed?
Yes
No
Where did you get this cat from?
Chemung County SPCA
Friend/relative
Found as a stray
Other shelter/humane society
Other (please describe)
Why are you surrendering your cat to the shelter? (check all that apply)
Time commitment
Family issues
Health issues (yours or cat)
Financial reasons
Biting/aggression
Litter box issues
Spraying
Scratching furniture
Not getting along with other pets
Not getting along with children
Other (please describe)
Please explain in your own words why you need to relinquish your cat
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your cat lived with? (check all that apply)
Has never lived with other animals
Cats
Dogs
Other (please describe)
How would you describe your household?
Active
Noisy
Average
Quiet
Is there some type of assistance that we may provide that could help you keep your cat, such as help with spay/neuter, behavior counseling, medical assistance, cat food, or support?
Typical Behaviors for Your Cat
Please answer the following questions in this section with how your cat USUALLY behaves
How would you describe your cat's personality? (check all that apply)
Friendly
Shy
Independent
Fearful
Playful
Affectionate
Aloof
Aggressive
Vocal
Describe your cat's personality in your words:
How many hours a day is your cat used to being left alone?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hrs
Where does your cat spend most of their time?
Inside
Outside
Inside/Outside
What does your cat do when they go outside? (check all that apply)
Stays close to the house
Wanders off
Fights with other cats
When inside, where does your cat spend most of their time?
Does your cat like to sit in your lap?
Yes
No
Does your cat like to be petted?
Yes
No
What do they do when they don't want to be petted/have had enough petting?
Does your cat like to be picked up?
Yes
No
What do they do when they don't want to be picked up?
Are there any parts of their body that they don't like touched?
Yes
No
Which body parts do they not like touched? (check all that apply)
Head
Paws
Tail
Stomach
Other (please describe)
Will your cat allow you to trim their nails?
Yes
No
Never tried
How does your cat react to being brushed?
Enjoys
Tolerates
Dislikes
Never tried
How would you describe your cat's behavior around children?
Playful
Calm
Avoids
Shy
Friendly
Tolerant
Dislikes
Outgoing
Never been around children
Would you recommend that this cat be placed with children?
Yes
No
If yes, how old should the children be?
Is your cat afraid of or uncomfortable with any of the following? (check all that apply)
Women
Men
Children
Infants
Strangers
None of the above
What does your cat do when they are uncomfortable?
Runs away
Hides
Hisses
Scratches
Bites
How does your cat interact with other cats?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around other cats
How does your cat interact with dogs?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around dogs
Does your cat spray indoors (territory marking, urine on vertical surfaces)?
Yes
No
What type of litterbox do you have?
Uncovered
Covered
Other (please describe)
How many boxes do you have?
Where are they located?
What type of litter do you use?
Clay
Clumping
Other (please describe)
Does your cat ever eliminate outside the litterbox?
Urinates only
Defecates only
Urinates and defecates outside of the litterbox
Never eliminates outside of the litterbox
How frequently?
Daily
Weekly
Once in awhile
Where do they eliminate if not in the box?
How long has your cat been inappropriately eliminating outside the litterbox?
Did your cat ever receive medical treatment for house soiling?
Yes
No
What have you tried to help the inappropriate elimination?
Does your cat like to play?
Yes
No
What is their favorite game or toy?
Where does your cat sharpen their nails?
Couch/chair
Scratching post
Rug
Other (please describe)
Where does your cat like to sleep?
Couch
Chair
Bed
Cat bed
Other (please describe)
Does your cat do any of the following (check all that apply):
Jump on counters or tables
Climb the curtains
Hiss or bite
Pounce on people
Exhibit fearfulness or shyness
Catch mice or birds
None of the above
What is your cat's best quality?
What is your cat's worst quality?
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Does your cat show aggression towards (check all that apply):
Family members
Visitors
None of the above
How does your cat show aggression (check all that apply):
Hiss
Swat at
Scratch
Bite
What do you do when your cat becomes aggressive?
Medical History
When was the last time your cat was seen by a veterinarian?
Never
3 months ago
6 months ago
Last year
Longer ago than last year
Veterinarian Name
Area Code
Phone Number
Email
Does your cat have any health problems or old injuries
Yes
No
If yes, please describe
Is your cat currently on any medications or a special diet?
Yes
No
If yes, please describe
Please indicate what kind of food your cat currently is given and how often:
Rows
Once daily
Twice daily
Free food
Only occasionally
Never
Dry Food
Canned Food
What is the brand name of the dry food they are given?
What is the brand name of the canned food they are given?
Is there anything else we should know about your cat?
Information for Cat 4
Detailed Cat and Household Information
Please answer these questions for each specific animal
Fourth Cat's Name
Sex
Male
Female
Unknown
Age (years) - please enter zero if the animal is under a year old and indicate the number of months in the question below
Age (months)
Breed
Color
How long has this cat lived with you (please indicate years/months)
Is this cat spayed/neutered?
Yes
No
Don't know
How old was your cat when they got spayed/neutered? (please indicate if years or months)
Has this cat been declawed?
Yes
No
Where did you get this cat from?
Chemung County SPCA
Friend/relative
Found as a stray
Other shelter/humane society
Other (please describe)
Why are you surrendering your cat to the shelter? (check all that apply)
Time commitment
Family issues
Health issues (yours or cat)
Financial reasons
Biting/aggression
Litter box issues
Spraying
Scratching furniture
Not getting along with other pets
Not getting along with children
Other (please describe)
Please explain in your own words why you need to relinquish your cat
Including yourself, how many people of the following ages live in your house? Please fill in the boxes
Rows
Female
Male
0-3 years old
4-9 years old
10-17 years old
18-29 years old
30-59 years old
60+ years old
What other animals has your cat lived with? (check all that apply)
Has never lived with other animals
Cats
Dogs
Other (please describe)
How would you describe your household?
Active
Noisy
Average
Quiet
Is there some type of assistance that we may provide that could help you keep your cat, such as help with spay/neuter, behavior counseling, medical assistance, cat food, or support?
Typical Behaviors for Your Cat
Please answer the following questions in this section with how your cat USUALLY behaves
How would you describe your cat's personality? (check all that apply)
Friendly
Shy
Independent
Fearful
Playful
Affectionate
Aloof
Aggressive
Vocal
Describe your cat's personality in your words:
How many hours a day is your cat used to being left alone?
Never
1-3 hours
4-8 hours
9-12 hours
Over 12 hrs
Where does your cat spend most of their time?
Inside
Outside
Inside/Outside
What does your cat do when they go outside? (check all that apply)
Stays close to the house
Wanders off
Fights with other cats
When inside, where does your cat spend most of their time?
Does your cat like to sit in your lap?
Yes
No
Does your cat like to be petted?
Yes
No
What do they do when they don't want to be petted/have had enough petting?
Does your cat like to be picked up?
Yes
No
What do they do when they don't want to be picked up?
Are there any parts of their body that they don't like touched?
Yes
No
Which body parts do they not like touched? (check all that apply)
Head
Paws
Tail
Stomach
Other (please describe)
Will your cat allow you to trim their nails?
Yes
No
Never tried
How does your cat react to being brushed?
Enjoys
Tolerates
Dislikes
Never tried
How would you describe your cat's behavior around children?
Playful
Calm
Avoids
Shy
Friendly
Tolerant
Dislikes
Outgoing
Never been around children
Would you recommend that this cat be placed with children?
Yes
No
If yes, how old should the children be?
Is your cat afraid of or uncomfortable with any of the following? (check all that apply)
Women
Men
Children
Infants
Strangers
None of the above
What does your cat do when they are uncomfortable?
Runs away
Hides
Hisses
Scratches
Bites
How does your cat interact with other cats?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around other cats
How does your cat interact with dogs?
Playful
Tolerant
Avoidance
Aggressive
Fearful
Never been around dogs
Does your cat spray indoors (territory marking, urine on vertical surfaces)?
Yes
No
What type of litterbox do you have?
Uncovered
Covered
Other (please describe)
How many boxes do you have?
Where are they located?
What type of litter do you use?
Clay
Clumping
Other (please describe)
Does your cat ever eliminate outside the litterbox?
Urinates only
Defecates only
Urinates and defecates outside of the litterbox
Never eliminates outside of the litterbox
How frequently?
Daily
Weekly
Once in awhile
Where do they eliminate if not in the box?
How long has your cat been inappropriately eliminating outside the litterbox?
Did your cat ever receive medical treatment for house soiling?
Yes
No
What have you tried to help the inappropriate elimination?
Does your cat like to play?
Yes
No
What is their favorite game or toy?
Where does your cat sharpen their nails?
Couch/chair
Scratching post
Rug
Other (please describe)
Where does your cat like to sleep?
Couch
Chair
Bed
Cat bed
Other (please describe)
Does your cat do any of the following (check all that apply):
Jump on counters or tables
Climb the curtains
Hiss or bite
Pounce on people
Exhibit fearfulness or shyness
Catch mice or birds
None of the above
What is your cat's best quality?
What is your cat's worst quality?
Aggressive Behavior
Please answer the following questions in this section with behavior that has EVER happened
Does your cat show aggression towards (check all that apply):
Family members
Visitors
None of the above
How does your cat show aggression (check all that apply):
Hiss
Swat at
Scratch
Bite
What do you do when your cat becomes aggressive?
Medical History
When was the last time your cat was seen by a veterinarian?
Never
3 months ago
6 months ago
Last year
Longer ago than last year
Veterinarian Name
Area Code
Phone Number
Email
Does your cat have any health problems or old injuries
Yes
No
If yes, please describe
Is your cat currently on any medications or a special diet?
Yes
No
If yes, please describe
Please indicate what kind of food your cat currently is given and how often:
Rows
Once daily
Twice daily
Free food
Only occasionally
Never
Dry Food
Canned Food
What is the brand name of the dry food they are given?
What is the brand name of the canned food they are given?
Is there anything else we should know about your cat?
Submission
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