Is this request routine or urgent?(Required)RoutineUrgentAgency Name/Town:(Required)Which CHS location are you closest to?(Required)Newington (701 Russell Road)Waterford (169 Old Colchester Road)Wilton (863 Danbury Road)Agency Member Name:(Required) First Last Best way to contact you:(Required)Phone number or email addressAre you a municipality or 501c3 rescue?(Required)Yes, municipal shelterYes, 501c3 rescueNeitherPlease specify your agency type:Impound/Intake Number(Required)Date of Impound/Intake(Required) Month Day Year How did you acquire this pet?(Required)Owner SurrenderStrayConfiscated/SeizedOtherIf other, please specify how you acquired this pet:Does your agency have legal ownership of this pet?(Required)YesNoIf no, when will you?Has this pet been scanned for a microchip?(Required)YesNoIf yes, result?Pet's Name(Required)Species?(Required)DogCatOtherIf other:Breed(Required)Age(Required)Is this pet up to date on vaccinations?(Required)Yes, Rabies and DistemperYes, Rabies onlyYes, Distemper onlyNoAre veterinary records available for this pet?(Required)YesNoIf no, explain:Has this pet been to a veterinarian while in your care?(Required)YesNoDetails:(Required)What services are you requesting and why are you requesting assistance?(Required)Please specify.How much is your agency able to contribute toward this care?(Required)Please explain how providing this support will improve this pet's chances of finding placement:(Required)Attach Pictures of Pet(Required)Max. file size: 256 MB. Attach estimate for veterinary care:Max. file size: 256 MB. Attach medical records:Max. file size: 256 MB. Do you authorize CHS to use photos of you and/or this pet for promotional purposes?(Required)YesNoSharing the good work of CT Humane Society is key to inspiring the community to support this program and make it available for pets in need. CT Humane Society may use photos of the pet(s) and their name(s) for this purpose. We will not use confidential legal guardian information, like your name, without your consent.Electronic Signature(Required)By signing, I attest that I have legal ownership of the above pet and that the information provided on this application is true and accurate to the best of my knowledge.Date(Required) MM slash DD slash YYYY
