Puppy Report Form

If you have purchased a sick or healthy puppy from an Illinois pet store, Illinois breeder, or an Internet site, please fill out our Puppy Report Form below. A member of The Puppy Mill Project will contact you.

Puppy Report Form

Your First and Last Name
Your Address
AddressAddress Line 2CityState / Province / RegionPostal / Zip Code

Country
Your Email Address

Pet Store Information

Pet Store Name *

Pet Store Address *

AddressAddress Line 2CityState / Province / RegionPostal / Zip Code

Country

Pet Store Website

Pet Store Veterinarian

How did you find this pet store?

Breeder Broker Information

Breeder's Name

Breeder's Address

AddressAddress Line 2CityState / Province / RegionPostal / Zip Code

Country

Broker's Name

Broker's Address

AddressAddress Line 2CityState / Province / RegionPostal / Zip Code

Country

Puppy Information

Did you purchase your puppy online thru the internet?

YesNo

Date of Purchase

Breed of Puppy

Sex of Puppy

FemaleMale

Please tell us about your puppy.

Verification

Please enter any two digits with no spaces (Example: 12)
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