PGI New Dog Intake

Todays Date *

Animal's Name *

Date of Intake to PGI (date of change of ownership) *

Dog intake from *

• Shelter to Paws Giving Independence
• Breeder Donation
• Owner Relinquish

Animals Date of Birth *

Animal TypeDog

Breed

GenderMaleFemale

Name of current Vet and Town

Vet Care History Dates/ Details

Have you given flea or heartworm medication: what med and when?

Current Owner's Name/ Or shelter Info *

First

Last

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Do you own this animal? This answer must be Yes to surrender a dog *yesno

Email *

File Upload- upload vet records, pictures, etc here

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

By signing this document, I attest that my organization is the sole and lawful owner of the aforementioned animal.  I affirm that, by signing this form, my organization permanently and forever waive any and all rights whatsoever that I have to the aforementioned animal. I understand that the animal become the property of Paws Giving Independence on the date listed above with my signature to this document. I attest that there have been no promises made to me with regard to the animal, no force used against me to get me to relinquish the animal, and no threat of force used against me that made me relinquish this animal. I am doing this act freely and voluntarily.  I certify that Paws Giving Independence owe me $0.00 for payment in relation to acquiring this animal.  I understand that I am responsible to pay all outstanding bills for veterinary care, food and supplies that I was extended with regard to the animal despite the animal being surrendered to Paws Giving Independence before (intake date listed above).  I understand that, should Paws Giving Independence have to defend against litigation or any case in relation to this surrender, I agree to pay all court costs and Paws Giving Independence’s attorney’s fees accrued in association therewith. I testify that the above information is complete and true to the best of my knowledge, and that I have never been charged with cruelty to animals.  By signing this, I give Paws Giving Independence permission to review all veterinarian records in regards to this animal. *Agree

Signature *

Clear Signature

PGI Authorized Signature and Date

Submit