COLUMBUS HUMANE SOCIETY, INC.
POST OFFICE BOX 742
WHITEVILLE, NORTH CAROLINA 28472
(910) 640-3700
Description of animal_______________________________________________________________________________________
Stray? No _____
Yes______ Where found?
_________________________________
Vaccinations Received
_____________________________________________________
Name of
Veterinarian:______________________________________________________
Declawed: No______
Yes______ Rabies Shot: No _____Yes _____ Tag #
_______________
Heartworm Prevention: No_____
Yes_____ Type of Prevention
___________________
Housebroken: No______
Yes_______ Good with
Children: No______ Yes________
Reason for Surrender ________________________________________________________________________________________________________________________________________________
STATEMENT
OF SURRENDER:
I certify
that I do/do not own this animal described above and I hereby surrender all my
interests, if any, to the Columbus Humane Society, Inc. It is expressly agreed that neither the
Columbus Humane Society, Inc. or the Officers and Volunteers will incur any
obligation to me on account of the disposition of this animal.
In the
event that I return to adopt this animal, I understand that the animal will be
altered before returning to me and that I will pay whatever costs are
involved.
I CERTIFY
THAT THIS ANIMAL HAS/HAS NOT BITTEN ANY ANIMAL OR HUMAN IN THE PAST 10
DAYS.
Name_______________________________Home Phone_____________Work Phone _____________
Street
Address____________________________________County_____________________________
City/State/Zip_______________________________________Donation
$_______________________
Printed
Name__________________________________Rec’d
by:_______________________________