Apply to Surrender

First Name*
Last Name*
eMail Address*
eMail Address Confirm eMail Address
Street Address*
Suite or Unit Number
City*
Province*
Postal Code*
Country
- Phone*
Reptile's History
Hidden
Dog Default Status: Submitted
- Are you the legal owner of the reptile?*
  - Yes
  - No
- Please Explain*
- Are you the only owner of the reptile?*
  - Yes
  - No
- Please Provide Other Owner's Name:*
- Other Owner's Phone #*
How Long Have You Had This Reptile?
- How Was The Reptile Obtained?
- Please Explain
- Breeder's Name (if Known)
- Why Are You Giving Up The Reptile?*
- Please Explain*
- Please Explain The Behavior Issues*
- Please Explain The Health Issues*
- Please Explain Care Needed*
Veterinarian Information
Do You Have a Veterinarian?
- Yes
- No
Name of Clinic
Name of Vet
Street Address
Suite or Unit Number
City
Province
Postal Code
Phone

- Reptile's Name*
- Primary Breed*
- Breed Name*
- Secondary Breed
- Breed Name
- Primary Color
- Which Color?*
- Secondary Color
- Which Color?*
Gender
- Male
- Female
Reptile's Date of Birth (If Known)
Month
Day
Year
Weight
Energy Level
- Good With Kids?
- Are There Any Special Needs?
  - Yes
  - No
- What Special Needs?
  Select All That Apply
Description of the Reptile
Featured Image
Accepted file types: jpg, jpeg, png, gif.
750 Wide x 750 High in Pixels
Additional Photos of The Reptile
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 1 MB, Max. files: 3.
Upload Photos of the Reptile (minimum of 3 - include one head shot, one full body) and 750 Wide x 750 High in Pixels

Reptile's Disposition
Is Reptile Good With Other Animals?
Is Reptile Good With Kids?
Reptile's Temperament
Select All That Apply
Fear & Agression
- Has Reptile Ever Bitten Anyone?
- Please Explain*
Is there anything else you would like to let us know about the Reptile's disposition?
Notes
Is there anything else you would like to let us know?
"Authorization: I hereby certify that I am the rightful guardian of the reptile who is the subject of this Surrender Application Form. I hereby surrender any and all property rights to the reptile to Little RES Q. I certify that no other person has a right of property to the reptile. I have disclosed all material information regarding the medical and behavioral history of the reptile. I understand that once I relinquish the animal, the reptile will not be available to be returned and Little RES Q has no obligation to follow up with information about the animal. I hereby release and forever discharge Little RES Q from any and all rights, claims, obligations, liabilities, and causes of action whatsoever arising out of or relating to the ownership, possession, or disposition of the reptile, and I agree to indemnify and hold harmless Little RES Q from and against any and all such rights, claims, obligations, liabilities, and causes of action which may be asserted by third parties. I have fully read and understand this Surrender Agreement. I accept and agree to abide by its terms. This Form's submission is NOT a guarantee that Little RES Q will take your reptile. "*
- Yes
Signature
Comments
This field is for validation purposes and should be left unchanged.

Reptile's History

Veterinarian Information

Eating

Reptile's Disposition

Fear & Agression

Notes

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