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2. First Name*
3. Last Name*
4. Phone Number*
6. Street Address*
7. City*
8. State*
10. ZIP*
11. CHIP #
12. DL #*
14. Date of Birth*
    Date of Birth
15. Email*
17. Pet's Name (if known)*
18. Age
19. Breed
20. Color
22. Animal Type*
    -- Select One --DogCatOther
23. Animal Type (if other)
24. Sex of Animal*
    -- Select One --FemaleMale
26. Acknowledgement
    I release the City of Waukee, their officers, employees, agents and volunteers, from all claims, liabilities, expenses, or judgements, arising from the acceptance, destruction and/or other disposition of this animal. I declare under penalty of perjury that the information provided here is true and correct to the best of my knowledge.
28. Electronic Signature*
29. Date*
    Date
Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field