S.T.I.C.K.S. Transport Request

For questions or comments about this S.T.I.C.K.S. Transport Request form please send an email.

All requested information is Required.

Please enter the information below in the event we need more information or clarification from the person completing the form.

Name : First : Last :

email address: phone number

Information - Originating Shelter / Rescue.

Primary Contact Person

First : Last :

e-mail:

Telephone (home) : Cell phone :

Street Address : City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Maryland 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 West Virginia Wisconsin Wyoming Zip:

Name of person responsible for meeting transport with the animal - First : Last :

If the meeting contact is not the same as the primary contact please enter the address and phone numbers (home and cell)

Sending Rescue / Shelter Information

Rescue / Shelter Name :

e-mail:

Telephone (home) : Cell phone :

Street Address : City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Maryland 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 West Virginia Wisconsin Wyoming Zip:

Information - Receiving Shelter / Rescue.

Primary Contact Person

First : Last :

e-mail:

Telephone (home) : Cell phone :

Street Address : City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Maryland 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 West Virginia Wisconsin Wyoming Zip:

Name of person responsible for meeting transport with the animal - First : Last :

If the meeting contact is not the same as the primary contact please enter the address and phone numbers (home and cell)

Receiving Rescue / Shelter Information

Rescue / Shelter Name :

e-mail:

Telephone (home) : Cell phone :

Street Address : City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Maryland 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 West Virginia Wisconsin Wyoming Zip:

Information about the animal being transported

ALL ANIMALS MUST HAVE A COLLAR WITH IDENTIFICATION SECURELY ATTACHED.

If a collar and tag are not available STICKS will supply one with an ID tag for an additional $5.00 donation.

Species: dog cat

Breed: Weight: Age:

Temperament:

Special needs (if any)

Will animal(s) have collars and ID tags supplied when transfered to STICKS? Yes No

If not, you understand they are required to have identification tags and these will be supplied - an additional $5.00 donation is requested to cover the cost of these collar and ID tag.

Donations to cover expenses

We ask that a donation is made to help cover the expenses of transporting the animal(s).

• $125.00 per Large Dog
• $100.00 per Small to Medium dog
• $75.00 per Cat or Kitten
• $125.00 for Mom and pups if in the same crate.
• $5.00 for collar and ID tag if not supplied

Please review the above information and if correct on to the next page.