Personal Pet(s) Relinquishment Form
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Name:
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Address:
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City:
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State:
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Zip:
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Home Phone:
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Cell Phone:
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Email Address:
Relinquished Animal Information
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Name of Pet (s). If this is a litter of puppies, please enter LITTER as the name
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Pet is a:
Intact Male
Intact Female
Neutered Male
Spayed Female
Litter of Puppies - Mixed Genders
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Approx. age or known date of birth of pet(s):
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Pet(s) Breed:
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Pet(s) coat color and distinguishing marks:
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Has this pet(s) had any previous veterinary care?:
If so, please list the name of the veterinary clinic and phone number where the pet(s) was seen:
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Do you certify that the above named pet(s) have NEVER shown any type of aggression to people or other animals?
Yes
No
If they have, please explain the situation IN DETAIL:
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Are all the animals listed above current on vaccines, heartworm prevention, & flea/tick prevention?
Yes
No
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If they are not vaccinated, on heartworm prevention, or on flea/tick prevention, please tell us why:
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Please list the names and ages of all people the above named pet(s) have lived with:
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Please list the types of other animals the above named pet(s) have lived with:
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Where has the above named pet(s) been kept while you were not at home:
Outside loose
Outside on a chain
Outside in a pen
Inside loose
Inside in a kennel
Inside confined to a specific area
At pet daycare/boarding facility
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Where has the above named pet(s) been kept when you were at home?
Outside loose
Outside on a chain
Outside in a pen
Inside loose
Inside in a confined area
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What are your reasons for relinquishing the above named pet(s):
Please provide any and all information you would like for us to know about the above named pet(s):
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I certify that I am the true and lawful owner of the above named pet(s), and I have full legal rights to surrender this/these pet(s) to Southern States Bully Breed Rescue
True
False
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By completion of this form, you understand that once the above named pet(s) are relinquished to Southern States Bully Breed Rescue, you will no longer receive any information regarding these pets.
I Agree
I Disagree
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Do you agree that by completion of the above form, you relinquish ANY and ALL rights to the above named pet(s) to Southern States Bully Breed Rescue. Southern States Bully Breed Rescue will be the sole entity to determine the future of the above named pet(s).
I Agree
I Disagree
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