Owner Surrender Form Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCounty *Phone Number *Email *Driver's License or Picture ID # and State Issued *Pet InformationPet's Name *Type of Animal *CatDogGender *FemaleMaleOtherSpayed/Neutered? *YesNoUnknownAge *Weight *Color or Pattern *Breed(s) *How long have you had this pet? *Is the pet housebroken? *YesNoUnknownIs this pet crate trained? *YesNoUnknownIs the pet good with dogs? *YesNoUnknownIs the pet good with cats? *YesNoUnknownIs the pet good with children? *YesYes, ages 0-3 yearsYes, ages 4-11 yearsYes, ages 12-18 yearsNoUnknownHas this pet bitten any individual or another animal? (If yes, please explain) *Medical InformationHas this pet ever had veterinary care? *YesNoNot sureName of Veterinary ClinicPhone Number of Veterinary ClinicCan you provide medical records for this pet? *YesNoAny known health or medical issues? *Please provide a detailed reason for surrender. *Are you the owner, or duly authorized agent of the owner, of this animal *YesNoAnimal is a strayProof of ownership to be provided:PhotosVet RecordsCounty LicenseOtherPlease upload pictures of your animal. Click or drag a file to this area to upload. Please read the below paragraph. Indicate that you have read the information by including your name and the date in the box below. *Pursuant to Forsyth County Ordinance Sec. 6.1: Owner: Any person, organization, group of persons, or association that has a property right in an animal, keeps or harbors an animal, has animal in their care or acts as a custodian of an animal for seven (7) or more consecutive days, except for a temporary care taker acting on behalf of the animal’s owner and excluding the county animal shelter and every nonprofit animal welfare agency that operates an animal sheltering facility registered by the Animal Welfare Section of the North Carolina Department of Agriculture and Consumer Services. As the owner, or duly authorized agent of the owner, at this time I am transferring custody/ownership and voluntarily surrendering the animal to the Forsyth Humane Society. I hereby consent to the disposition of the animal before the expiration of the minimum 72 hour holding period, through either adoption, transfer, or humane euthanasia, in accordance with NC General Statue 19A-32. I understand that I have no guarantees of placement for the animal and relinquish all ownership of the animal.NameSubmit8190
