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Personal Information * Name (First and Last): * Street Address: *City: *State: *Zip Code: * Home Phone: Cell Phone: *Email: Work Phone: Can we contact you at work? Yes   No Hours you are at work Days you are at work

Dog Information Name:              Date of birth (if known): Breed: Purebred? Yes No   If a mixed breed, list which breeds:   AKC Registered? Yes No   Registration #:   Papers should be faxed or emailed to CBR-West   Has your beagle been altered (spayed or neutered)? select one yes no Not sure Gender: select one male female This beagle would be considered a: select one owner surrender stray   Age of beagle when you acquired it:   Acquired from:   How long have you had this dog?   Please describe IN DETAIL the reason(s) for relinquishing this dog):     If your beagle was obtained from a breeder, have you contacted the breeder to see if the dog may be returned? Yes No Who was the breeder? How can we contact them?     Dog's Behavior Traits Does/is your dog....? (Please check all that apply and add any that are not listed):   bark excessively dig Other: bite destroy property mouth/nip have separation anxiety jump fences aggressive towards other dogs rides well in car aggressive towards people housebroken aggressive towards children playful aggressive towards cats and/or other animals obedient likes other dogs smart likes people gentle likes children sweet likes cats and/or other animals         What is the worst thing about your beagle? What is the best thing about your beagle? What tricks (if any) does your beagle know? Has your beagle completed obedience classes? Yes No Does your dog live with? (Please check all that apply)     children     other dogs     cats   Where does your beagle sleep? Is your beagle allowed on the furniture? Yes No Is your beagle allowed on the bed? Yes No Is your beagle crate-trained? Yes No

List your dog's current veterinarian: Phone number of veterinarian's office: List any health issues that your dog has: List any medications that your dog is taking: Does your dog have any allergies? Yes No Is your dog microchipped? select one yes no not sure   If yes, please list the ID number:   Vaccinations Date given: Due: DHLPP Rabies Bordetella Lyme           What brand of dog food does your dog eat?     What will you send along with your dog to its new home? (toys? bed? crate? collar? leash? food? medications? etc.)

Where did you hear about CBR? Internet Search/Web Petfinder Word of Mouth/Friend Sign or Poster Newspaper Article Rescue Which one? Shelter Which one?   Other (please explain)       *I  hereby certify that the above listed information is true and accurate to the best of knowledge. (print name)     Note: After completing this online form, another form will need to be downloaded, completed, signed, and faxed to: 1.866.202.4223 or mailed to the address at the top of this form.  You will be given the link after this form is submitted.**

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