Owner First Name *
Owner Last Name *
Home Telephone *
Cell Phone *
Address *
Apt/Lot #
City *
State *
Zip Code *
Driver's License Number *
Driver's License State *
Please upload a photo of driver's license here *
Please upload, scan, or screenshot a copy of your license or government ID.
Does your Drivers License match the above address? *
No Yes
Email Address *
Is the person filling out the form the owner? *
No Yes
If no, what is your relationship to the owner?
County and State where you currently live: *
Do you live in Bristol City or Kingsport City? *
No Yes
How long have you lived at the above address? *
Are you surrendering a cat/kitten or a dog/puppy? *
cat/kitten
dog/puppy
Have you adopted from us or surrendered to us before? *
No Yes
If yes, what is the animals name and when?
Using the scale, please rate the activity level of the animal (1 being a couch potato/5 being wild child)
1
2
3
4
5
Animal Name 1 *
Is animal number 1 a male or female or Unknown *
male
female
unknown
Breed of animal number 1 *
Animal Number 1 Age *
Upload photo of animal number 1 *
Is this animal spayed/neutered? *
No Yes
Does this animal live inside, outside, or both? *
Inside
Outside
Both
Is this animal up to date on vaccines? (1 year) *
No Yes
How long have you owned this animal and where did you get the animal? *
Does this animal do well with dogs, cats, kids or none of the above? *
Dogs
Cats
Kids
None of the Above
Animal Name 2
Is animal number 2 a male or female
male
female
unknown
Breed of animal number 2
Animal Number 2 Age
Upload photo of animal number 2
Is animal number 2 spayed/neutered?
No Yes
Does animal number 2 live inside, outside or both?
Inside
Outside
Both
Is animal number 2 up to date on vaccines? (1 year)
No Yes
How long have you owned this animal and where did you get the animal?
Does animal number 2 do well with dogs, cats, kids, or none of the above?
Dogs
Cats
Kids
None of the above
Animal Name 3
Is animal 3 a male or female
male
female
unknown
Breed of animal number 3
Animal Number 3 Age
Upload photo of animal number 3
Is animal number 3 spayed/neutered?
No Yes
Does animal number 3 live inside, outside or both?
Inside
Outside
Both
Is animal number 3 up to date on vaccinations (1 year)
No Yes
How long have you owned this animal and where did you get the animal?
Does animal number 3 do well with dogs, cats, kids, or none of the above?
Dogs
Cats
Kids
None of the above
Please list the name(s) and phone number(s) of the veterinarian you use for surrendered pets and past pets within the last 5 years: *
What person's name will the veterinary records be under? *
I here by authorize the release of the veterinary records for the above named animal(s). Please initial: *
Clear
Tell us a little about your pet(s) to help find them a home and why your surrendering? *
Has this animal ever bitten anyone? *
No Yes
If yes, please provide details such as who, what, when, where, why and how?
I do hereby release and forever discharge ASoSC from all rights, claims, obligations, liabilities, and cause of action whatsoever arising out of or relating to the ownership, possession, or disposition of the animal(s). I agree to indemnify and hold harmless ASoSC from and against any such rights, claims, obligations, liabilities, and cause of action which may be asserted by third parties. This is a legally binding document for the irrevocable surrender of any animal to ASoSC. *
Clear
Please list what brand of food your animal currently eats.
I hereby do voluntarily and irrevocably give, donate, surrender, release this to the Animal Shelter of Sullivan County (ASoSC) the above names animals (named on page 1). I represent and warrant that I am the lawful owner of the above names animal(s) to ASoSC. I affirm that no other person or organizations has legal or equitable ownership interest in the animal(s) names on page 1. I have disclosed to the ASoSC all material information regarding medical and Behavioral of the animal(s). I further acknowledge that I am releasing this/ these animal(s) completely and voluntarily and that no representation, considerations, or promises have been made to me by the ASoSC or any of it's representatives. I understand that by signing below that my contact with the animal(s) terminates at the time of surrender and that ASoSC is under no obligation to provide any follow up details regarding the animal(s). *
Clear
