First name:

Last name:

Address 1:

Address 2:

City: State: IllinoisWisconsinMichiganIndianaMissouriMinnesotaOhioIowa Zip code:

Home Phone: ( ) -

E-mail address:

Are you a current CHS member: YesNo Age:

Type of Animal:

Reason for Placement:

Health Problems: NoYes Note: Unhealthy animals may be refused placement

Size (approx length/weight, etc):

Housing Provided: Yes-DescribeNo

Detail:

Is animal eating: NoYes

Current Diet (i.e. type of food, frequency, quantity, etc.):

 How long have you had this animal: Less than one yearOne year to two yearsTwo years to five yearsFive years to ten yearsOver ten years