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Submitter Information

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Your Information
You must be 18 years of age or older to submit a request
First Name*
Last Name*
Address*
Apt #
City*
State
Zip*
Contact information
How would you like us to follow up with you? Please provide us with a valid email or phone number, as we may need to follow up with you on your request.
Email*
Primary Phone*
Alternate Phone
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Description of Animal
Animal Type*
Animal Size*
What kind of animal was it?
Breed (if known)
Color(s)
Age (if known)
Animal Name (if known)
Did attack involve a bite?
1. Yes
1. No
Is the owner known?
1. Yes
1. No
Name of owner
Describe what happened*
Information such as injuries received (for attacks or bites), apartment/business location within complex, gate codes to access property, non-major crossroads, description of unknown person that might be the owner of the dog/cat, etc.

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