Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please Check All: *

I hereby certify that I am the rightful owner/keeper/caretaker/custodian of the animal(s) who is/are the subject of this Animal Surrender Form, hereinafter referred to as “the animal.”

I hereby surrender any and all property rights to the animal. I certify that no other person has a right of property to the animal.

I understand that by surrendering my property rights to the animal, the animal may be transferred into the custody of an animal shelter, animal rescue group, or foster home.

I hereby certify that to the best of my knowledge, the animal has not bitten a human or another animal within the past 10 days.

I hereby certify that to the best of my knowledge, the animal has not bitten a human and is not deemed dangerous.

I understand that once I relinquish this animal, the animal will not be available to be returned.

Please complete the section below (include all animals):

(If surrendering more than one animal please check all that apply.)

Dog

Puppy

Cat

Kitten

Small Animal

Litter

Date: *

MM

DD

YYYY