Intake | Hart County Animal Rescue

Intake Form

Name of Establishment or Person surrendering

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

How long have you had the animal?

I hereby certify (select one):

That I am the owner of the dog/cat and do hereby relinquish all rights of ownership and waive all claims, damages and indebtedness growing out of the action taken by Hart County Animal Rescue.

That the dog/cat that I am relinquishing to Hart County Animal Rescue was an animal running at large and is a stray. I have no knowledge of the ownership of this animal and do hereby relinquish all rights of ownership and waive all claims, damages and indebtedness growing out of the action taken by Hart County Animal Rescue.

It is important that you understand that by relinquishing this animal(s), you will not be able to determine its final disposition.

Signature

Hart County Animal Rescue Rep

Date

Donation

OWNER SURRENDER

Name of Pet

Age

Upload Picture of Surrendered Animal

Choose File

Type of Animal

Canine

Feline

Sex

Male

Female

Breed

Any Known Aggression? (if yes, understand we cannot take aggressive dogs towards humans)

Yes

Please explain Aggressive Behavior

Name of Vet Pet was last seen at

Reason Animal was Surrendered

Intake Form

OWNER SURRENDER

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