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  • Animal Relinquishment Form

     

     

    The Inland Valley Humane Society & SPCA

    Animal Relinquishment Form

    1. ANIMAL OWNER INFORMATION:

    *

    Name:

     

     

       

    *

    *

    *

    City/State/ZIP:

     

        

    *

    *

    Date of Birth:

     


    *2.  


    *3.  


    4.
    Question - Not Required - Date:




    *5.  


    *6.  


    7.  


    *8.  


    9.  


    *10.  


    11.


     

    Please provide proof of ownership (i.e., pictures, veterinary medical records, microchip registration) at the time of your relinquishment appointment.  

    *12.

    (Maximum response 255 chars, approx. 5 rows of text)

    *13.

    (Maximum response 255 chars, approx. 5 rows of text)

    *14.  


    15.

    (Maximum response 255 chars, approx. 5 rows of text)

    *16.


    17.


    18.  


    *19.


    20.  


    21.  


    *22.


    23.

    (Maximum response 255 chars, approx. 5 rows of text)

     

    Please rate your animal below on a scale of 1-5, with 1 being poor and 5 being excellent: 

    *24.
    Question - Required - Temperament:





    *25.
    Question - Required - Health:





    *26.
    Question - Required - Behavior:





    *27.
    Question - Required - House/Litter Box Training:





    28.

    (Maximum response 255 chars, approx. 5 rows of text)

    *29.

    (Maximum response 255 chars, approx. 5 rows of text)

    *30.  


    *31.
    Question - Required - Date:




     
    NOTICE: PURSUANT TO FOOD & AGRICULTURE CODE SECTIONS 31108.5(a)(2) AND 31752.2(b), ANY PERSON WHO PROVIDES FALSE INFORMATION PURSUANT TO THIS SUBDIVISION ABOUT HIS OR HER OWNERSHIP OF THE DOG/CAT SHALL BE LIABLE TO THE TRUE OWNER OF THE DOG/CAT IN THE AMOUNT OF ONE THOUSAND DOLLARS ($1,000). 
       Please leave this field empty