Cat Owner Surrender Form Animal InformationName Date of Surrender Month Day Year Age Primary Breed Primary Color Gender Male Female Altered Yes No Declawed Yes No Bitten Yes No If yes, please explain Veterinarian Name Medical History (if any)Reason for surrender Where did you get the cat? When did you get the cat? Owner InformationOwner Name Physical Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneThis is to certify that on this day I have irrevocably and legally surrendered my ownership, custody, and rights to this animal(s) to the Humane Society Waterville Area. I understand that no information regarding disposition of this animal will be released to me or my representatives or assignees. I understand that my surrender of ownership, custody, and rights to this animal is final and irrevocable and the animal(s) will not be returned to me under any circumstances. I understand the Humane Society Waterville Area will attempt to find the animal(s) a suitable home or humanely euthanize the animal(s) at their sole discretion.* I agree I will indemnify and hold the Humane Society Waterville Area harmless against all liability for any action taken by it in reliance on this agreement.* I agree This animal HAS NOT bitten any person or other animal within the last ten (10) days. The Humane Society Waterville Area does not accept owned animals that have bitten a person or other animal.* I agree My signature below states that I have read, understand, and accept the above conditions concerning the surrender of my animal(s) and also that to the best of my knowledge the information is correct.Signature* Date Month Day Year Δ
