Name *

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

When did you purchase this animal(s)? *

MM

DD

YYYY

What species(s) are you wanting to surrender? *

Dog

Cat

If you have more than one animal being surrendered, would you classify them as bonded?

Bonded: the animals must never be separated and be adopted together. If separated, they would become distressed and depressed.

Yes

No

Does the animal(s) have any symptoms of sickness? *

Ex. sneezing, coughing, nose/eye discharge, wheezing, laboured breathing, vomiting, diarrhea

Yes

No

I agree to the following: *

I understand that any information given will be held confidential. By checking below, I certify that the information I have provided is true and that any misrepresentation of facts may result in losing the option to surrender. I understand that the Carleton County Animal Shelter has the right to deny my request to surrender an animal, and I authorize the investigation of all statements in this application.

I agree

Date of agreement *

MM

DD

YYYY

Select from the following what we can help with during the wait.

Food (dry/wet)

Bedding (blankets, towels, pillows)

Carrier kennel for transport