ANIMAL INFORMATION FORM V3 (RECORDS - please register into ECM and distribute to Supervisor City Regulation

• Document No.

• Commenced

  Date

• Authorised Officer

  Select B SMITH M BALDWIN M O'CALLAGHAN G BIBLE A MCNEIL

  • B SMITH
  • M BALDWIN
  • M O'CALLAGHAN
  • G BIBLE
  • A MCNEIL

• Other Personnel

SEIZING INFORMATION

• Time Seized

  Date

• Type of Animal

  Select Dog Cat

  • Dog
  • Cat

• Gender

  Select Male Female Unsure

  • Male
  • Female
  • Unsure

• Colour

• Breed

• Location Seized
  Address

• Microchip No.

• Is The Animal Registered

  Yes

  No

  N/A

• Owners Name

• Contact Details

• Owners Address

• Second Contact Details

• Authorised Officers Name

  Sign

• Photo of animal

  Media

SEIZED / SURRENDERED / IMPOUNDED ANIMAL DECLARATION

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

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

• I surrender my dog / cat to the Authorised Officer, UNDERSTANDING THAT IT MAY BE DESTROYED.

• Insert name and sign.

  Sign

• Address (if not owner)

TRANSPORTATION OF THE ANIMAL

• Was the animal conveyed to the RSPCA, Owner or Agent

  RSPCA

  Owner

  Agent

• Tag Number

• Comments /Warnings

• Received by RSPCA

  Sign

• Received by owner

  Sign

• Received by Agent

  Sign

• Address

OFFICE USE ONLY

• Number of days impounded.

• Total of fees charged as per pound register.

• Receipt No.

• Animal identification number on release. M/C No.

• The animal mentioned was -

• Returned to owner/agent.

• Surrendered

• Transferred to RSPCA

• Stolen

• Destroyed

• Other

• Name of Owner/Agent

• Address of Owner/Agent

• Type of ID Provided by Owner/Agent

• Signature of Owner/Agent

• Notes:
  
  
  
  
  

• Pound Officers name

• Signed

• Date