ANIMAL INFORMATION FORM (RECORDS - Please register into ECM and distribute to Supervisor City Regulation)

• Document No.

• Impounded on

  Date

• Impounding/Seizing Officer

  BRS

  MAB

  MAO

  GKB

  JJA

• Other Personnel

SEIZING, IMPOUNDING, SURRENDER DECLARATION

• Seized, Impounded or Surrendered

  Select Seized Impounded Surrendered

  • Seized
  • Impounded
  • Surrendered

• I declare that the dog/cat was seized by virtue of the Companion Animals Act 1998. I was not able to establish the owner of the dog/cat, prior to surrendering the animal to the pound.

• I declare that the mentioned animal was impounded from a public place.

• I surrender my dog/cat to the Authorised Officer, understanding that it MAY BE DESTROYED.

• Name

  Sign
• Address
  Address

ORIGIN OF REQUEST

ANIMAL OWNER AND DETAILS

• Time & Date Seized/Impounded

  Date

• Animal Type

  Dog

  Cat

• Gender

  Male

  Female

  Unsure

• Name

• Colour

  Select Black White Brown Tri Colour Blue Red Brindle Other

  • Black
  • White
  • Brown
  • Tri Colour
  • Blue
  • Red
  • Brindle
  • Other

• Colour

• Breed

  Select Staffy Am Staff Shitzu Maltese Labrador German Shepherd Bull Terrier Kelpie Rottwieler Cattle Dog Poodle Other

  • Staffy
  • Am Staff
  • Shitzu
  • Maltese
  • Labrador
  • German Shepherd
  • Bull Terrier
  • Kelpie
  • Rottwieler
  • Cattle Dog
  • Poodle
  • Other

• Breed

• Photo of Animal

  Media
• Location of seizure
  Address

• Microchip Number

• Is Animal Registered

  Yes

  No

  Unknown

• Owners Name

• Owners Address
  Address

• Owners contact details

• Other notes if required

• Authorised Officers Name

  Sign

TRANSPORTATION OF ANIMAL

• Conveyed to RSPCA, Owner or Agent

  RSPCA

  Owner

  Agent

• Tag Number

• Items Impounded With Animal

  Yes

  No

• Items

• COMMENTS / WARNINGS

• RSPCA Impound Officer Name

  Sign

• Owners Name

  Sign
• Owners Address
  Address

• I am collecting the subject animal on behalf of the owner.

• Agents Name

  Sign
• Agents Address
  Address

OFFICE USE ONLY

• Date letter sent to last registered owner.

• Number of Days Impounded

• Total Amount of Fees Charged as per Pound Register

• Receipt Number

• Microchip No. On Release

• Notes :-
  
  
  
  
  
  

• Animal Released to:- OWNER - AGENT (Circle)

• ID Sighted

• Signed

• Name

• Address

• Date

• Animal was :- TRANSFERRED TO RSPCA - DESTROYED - STOLEN - (circle)
  

• Date

• RSPCA Pound Officers Name

• Signature