Rescue or Stray Surrender Agreement

Name of Person or Organization

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Phone Number

Type of Animal

Animal’s Name

Breed

Age

Sex

Male

Female

If surrendering a litter please provide names, gender and markings here.

Spayed/Neutered

Spayed

Neutered

Vaccinated

Yes

Please enter any vetting history (example flea treated with date)

Does your animal have any history of aggression if so please explain?

Reason for surrender/intake request?

Please Provide any additional information you feel is revelant

Voluntary Surrender

Agreement & Signature