First name:

Last name:

Address 1:

Address 2:

City: State: Illinois Michigan Indiana Ohio Zip code:

Home Phone: ( ) -

E-mail address:

Are you a current herp keeper?: Yes No Age:

*NOTE* Must be 18 or older or have guardians permission.

Type of Animal:

Reason for Placement:

Health Problems: No Yes

Note: Unhealthy animals may be refused placement depending on situation.

If ill or emaciated, what are symptoms or if known, what is the illness?

Size (approx length/weight, etc):

Housing Provided: Yes-Describe No

Detail:

Is animal eating: No Yes

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

 How long have you had this animal: Less than one year One year to two years Two years to five years Five years to ten years Over ten years