This Dog Intake Report is to be used by the person who physically accepts this dog in to BROOD and should be submitted online.

Note that Foster Families should fill out a Foster Dog Report rather than this form.

Dogs name? *

Shelter/Owner Name *

Shelter/Owner Street Address *

Shelter/Owner City *

Shelter/Owner State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming –U.S. Territories– American Samoa Federated States of Micronesia Guam Midway Islands Puerto Rico U.S. Virgin Islands

Shelter/Owner Zip *

Shelter/Owner Phone *

Please check the breed description that best applies * Purebred classic bassetPoorly bred basset or possible mixDefinite mixPurebred of another breed (beagle, etc.)

Dogs gender? *

Male
Female

Dog’s Age?

Where is the dog currently located? *

Other comments

Intake Volunteer Name *

Phone *

E-mail Address: *

Verification Code:

Enter Verification Code: *

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* Required