Animal Surrender Application

To triage our many calls regarding animals in need of a new home, we ask that you please fill out this form. Please note that filling out this form does not mean we can take in this animal. Our animal intake crew will review and process this form and contact you as soon as possible. Thank you for your patience.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are you over 18?

YesNo

Is the animal currently safe?

YesNo

Does the animal have food, water and shelter from weather?

YesNo

Type of animal you need to surrender?

Please specify

How many animals are there in total?

Are you the current owner of the animal?

YesNo

If you are the current owner of the animal, please answer the following five questions.

1. Is the animal spayed or neutered?

SpayedNeuteredNot Aware

2. Current on vaccinations?

YesNoNot Aware

3. Aggressive?

YesNoNot Aware

4. Known medical issues?

YesNoNot Aware

If yes, please describe.

5. Known bite history?

YesNoNot Aware

If yes, please describe.

If you are not the current owner of the animal, please answer the following two questions.

1. Is this animal a stray?

YesNoNot Aware

If yes, please describe current living conditions.

If no, do you know who the owner is?

2. Where was the animal found?

Why are you surrendering this animal?

Please read, sign and date.

I hereby release/relinquish rights and ownership of the animal(s) to Animal Nation, Inc. if accepted. I understand by submitting and signing this surrender application Animal Nation, Inc. is not obligated to take in the animal(s).

Signature

Date Signed

Animal Nation, Inc. | Post Office Box 72 | South Salem, New York 10590
501(c)3 non-profit | www.animalnation.org | info@animalnation.org