Name of Dog:

DOB (mm/dd/yyyy): (If unknown please estimate)

State:

SSMPR Tag Number:

Microchip Brand: resQ HomeAgain Avid 24 PetWatch Other

Microchip ID:

Confirm Microchip ID:

Implant date (mm/dd/yyyy):

Sex (M/F): Male Female

Breed: MinPin Other:

Primary Color

Secondary Color

Special Characteristics

Height (inches): Weight (pounds):

Spayed/Neutered: Yes No

Docked Tail: Yes No Don't Know

Cropped Ears: Yes No Don't Know

Health/Temperament Problems:

This Form was completed by SSMPR Volunteer:

Thank you for making a difference in the life of this little one.  May your dedication to rescuing this special fur kid be rewarded ten fold! Your form will be submitted to SSMPR Administration at SSMPR,Inc.