Please fill out the below incident report to the best of your ability. Attached photos of injury, if applicable.

1

Contact Information

 *

Contact Information

First Name	Last Name
Phone Numberext.	Email

2

Incident Information

 *

Incident Information

Date Incident Occured

Time Incident Occured

3

Type of Incident (Please selection one option below)

 *

Type of Incident (Please selection one option below)

Serious dog fight - no injuries, no vet bill	Serious dog fight - injuries, vet bill
Serious dog fight - injuries to human	Other (please explain in space provided) If other, type text here.

4

Incident Description

 *

Please provide a timeline of the incident including facts and descriptions of all involved.

5

Humans/Dogs Involved

Humans/Dogs Involved

Owner's First Name	Owner's Last Name
Phone Numberext.	Email
Dog's Name	Dog's Breed
Dog's Color

6

Other Humans/Dogs Involved

Other Humans/Dogs Involved

Owner's First Name	Owner's Last Name
Phone Numberext.	Email
Dog's Name	Dog's Breed
Dog's Color

7

Witness' #1 Information

Witness' #1 Information

Witness' #1 First Name

Witness' #1 Last Name

Witness' #1 Phone Numberext.

Witness' #1 Email

8

Witness' #2 Information

Witness' #2 Information

Witness' #2 First Name

Witness' #2 Last Name

Witness' #2 Phone Numberext.

Witness' #2 Email

9

Injury Photo(s)

Please provide a photo(s) of injury to individual and/or dog. Click button for uploading file Clear Maximum size allowed: 5 MB Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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