| Your name: |
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| Address: |
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| City/State: |
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| Zipcode: |
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| Email Address: |
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| Phone Number: |
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| Number of Chinchillas being surrendered: |
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| Chinchilla(s) name(s)?: |
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| Age(s) of chinchilla(s)?: |
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| Gender(s) of chinchilla(s)?: |
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| If one, or more of your chinchillas are female, have they been near a male within the past 120 days?: |
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| If there is more than one chinchilla, do they live together?: |
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| What type of food does your chinchilla eat?: |
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| Do your chinchillas come with their cage?: |
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| If so, please describe the cage, or cages.: |
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| Does your chinchilla come with any of its belongings? If so, please indicate what type of things: |
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