Animal Surrender Form

Please Complete the Following Information

Owner Information

Owner Name:

Contact Information:

Animal Information

Animal Name:

Species:

Breed:

Age:

Medical History:

Surrender Reason

Please explain why you are surrendering the animal:

Certification

By signing this form, I certify that:

• I am the legal owner of the animal.
• The animal has not bitten or scratched a human or another animal within the past 10 days.

Signature:

Date:

Surrender Form Submission

Please submit the completed surrender form to the animal shelter or rescue organization.