EmailMe Form - Shock Collar Abuse

EmailMeForm

Your personal information
Name
First Last
Email
Phone
### - ### - ####
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Please indicate what you are reporting

Please select one
Your pets' information
Name
First Last
Please upload a picture of your pet
Please only upload the following file types PDF, Jpeg, jpg, gif
Date of Birth
MM / DD / YYYY
Breed or Mixed Breed Description
Age at incident
The Incident
Please provide information about the incident
The name of the pet professional (if one was invovled)
First Last
The business location

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
The business website
Was the pet professional
A Dog Trainer
A Dog Behavior Consultant
A Veterinarian
A Groomer
A Pet Boarding Facility
A Dog Walker
A Pet Sitter
A Dog Daycare Facility
Other
If other, please give details
Please give details about the incident
What action if any did you take?
Did you officially report this incident to anyone and if so who? Please also detail what their responce was
Please upload a document here if you need more room to explain what happened
Please confirm that this piece of equipment was used on your pet without any prior knowledge or consent from you
Please choose the level of permission you grant to us for use of this information.
Signature
Clear
By signing here and submitting this form I attest that, to the best of my knowledge and belief, all the information contained in this form is accurate and complete

Your personal information

Your pets' information

The Incident