Inland Valley Humane Society and S.P.C.A.

Animal Relinquishment Form

The Inland Valley Humane Society & SPCA

Animal Relinquishment Form

1. ANIMAL OWNER INFORMATION:

Field Is Required First

Field Is Required Last

Field Is Required Date of Birth:

Field Is Required Street 1:

Field Is Required City/Town:

Field Is Required State / Province:

Field Is Required ZIP / Postal Code:

Field Is Required Email:

Field Is Required Phone Number:

Yes, I would like to receive postal mail from Inland Valley Humane Society & S.P.C.A.

2. Field Is Required Driver's License/State Identification Card/Passport or Other Legally Recognized Identification:

3. Field Is Required I state under penalty of perjury under the State of California that I am the legal owner of this animal. (Please type your name below)

4. Date:

5. Field Is Required Animal Name:

6. Field Is Required Species:

7. Breed:

8. Field Is Required Age:

9. Color:

10. Field Is Required Sex:

11. Spayed or Neuter:

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

12. Field Is Required Why are you relinquishing your animal? (Maximum response 255 chars, approx. 5 rows of text)

13. Field Is Required Have you tried rehoming your animal? (Maximum response 255 chars, approx. 5 rows of text)

14. Field Is Required How long have you owned your animal?

15. Where does your pet reside most of the time? (Maximum response 255 chars, approx. 5 rows of text)

16. Field Is Required Vaccinated:

17. Vaccine Records:

18. List the Vaccines Given:

19. Field Is Required Licensed:

20. Where was your pet licensed?

21. License Number:

22. Field Is Required Microchip-chipped:

23. Microchip Number: (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:

28. Details on the above ratings: (Maximum response 255 chars, approx. 5 rows of text)

29. Field Is Required Other information you would like us to know about your animal: (Maximum response 255 chars, approx. 5 rows of text)

30. Field Is Required By signing below, I state under penalty of perjury under the law of the State of California that all of the information provided above is true and accurate. (Please type your name in the box below)

31. Field Is 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).

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Animal Relinquishment Form

The Inland Valley Humane Society & SPCA

Animal Relinquishment Form