Owner Surrender Form

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 *

Does your Drivers License match the above address? *

Email Address *

Is the person filling out the form the owner? *

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? *

How long have you lived at the above address? *

Are you surrendering a cat/kitten or a dog/puppy? *

Have you adopted from us or surrendered to us before? *

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) *

Animal Name 1 *

Is animal number 1 a male or female *

Breed of animal number 1 *

Animal Number 1 Age *

Upload photo of animal number 1 *

Is this animal spayed/neutered? *

Does this animal live inside, outside, or both? *

Is this animal up to date on vaccines? (1 year) *

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? *

Animal Name 2

Is animal number 2 a male or female

Breed of animal number 2

Animal Number 2 Age

Upload photo of animal number 2

Is animal number 2 spayed/neutered?

Does animal number 2 live inside, outside or both?

Is animal number 2 up to date on vaccines? (1 year)

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?

Animal Name 3

Is animal 3 a male or female

Breed of animal number 3

Animal Number 3 Age

Upload photo of animal number 3

Is animal number 3 spayed/neutered?

Does animal number 3 live inside, outside or both?

Is animal number 3 up to date on vaccinations (1 year)

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?

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: *

Is the animal an escape artist? *

If so, provide details?

Has this animal ever received any professional training? *

Has this animal ever bitten anyone? *

If yes, please provide details such as who, what, when, where, why and how?

What was this pet's role in your life? Please check all that apply *

If pet was unwanted gift/companion from someone else please list their name and phone number. *

Who was primarily responsible for this animal's care? *

Where has this animal been primarily living? Please check all that apply *

If a cat, is this cat declawed?

If cat is declawed please list the veterinarian who performed declaw: *

How was this animal exercised?(Dog/Puppy Only) Please check all that apply

Are veterinary costs the main reason for surrender? *

If this animal sick, injured, or have a medical condition the shelter should be made aware of? *

If yes, please explain

Is the animal on medications currently? *

If yes, what and why?

What is the main reason for the surrender? Please check all that apply *

If yes, please explain:

Is there any situation in which the animal becomes aggressive? *

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. *

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). *