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2. Contact Information:
4. Name:
6. Address:
8. City:
10. State:
12. Zip:
14. Phone Number:
16. Email Address:
18. Was seen moving or resting in area.

    1. Yes
    2. No
20. Was seen resting in an area with people present or nearby.

    1. Yes
    2. No
22. Entered a private property with or without pets present (no injury).

    1. Yes
    2. No
24. Followed or approached a person with or without a pet.

    1. Yes
    2. No
26. Injured or killed a pet on private property without people present.

    1. Yes
    2. No
28. Injured or killed a pet on private property with people present.

    1. Yes
    2. No
30. Injured or killed a pet on public property.

    1. Yes
    2. No
32. Injured a person.

    1. Yes
    2. No
34. Additional Comments:
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

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