Title Page
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Time Date
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Officer/s Receiving
- Wayne Brooks
- Rebecca Creer
- Michael Gray
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CS Number
Animal Details
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Surrender Reason / Behavior concerns
- Unwanted
- Cannot keep the animal
- Owner moving cannot take animal
- Unable to contain
- Barks / Howls excessively
- Owner cannot train / control animal
- Destructive / Uncontrollable
- Aggressive to neighbors through fence
- Animal is too dominant for owner
- Aggressive to friends / family
- Attacked a person
- Attacked an Animal
- Other
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Animals Name
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Species
- Dog
- Cat
- Rooster
- Duck
- Pidgeon
- Large Birds (peacock / Geese / Guinee fowl Type)
- Ornamental Bird/s (parrot / canary / finch type)
- Other
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Breed Type
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Photographs
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Litter 1 numbers.
- N/A
- 1 x Adult Female (mother)
- 2 x Adult Females (mothers)
- 3 x Adult Females (mothers)
- 1 Pup
- 2 Pups
- 3 Pups
- 4 Pups
- 5 Pups
- 6 Pups
- 7 Pups
- 8 pups
- 1 Kitten
- 2 Kittens
- 3 Kittens
- 4 Kittens
- 5 Kittens
- 6 Kittens
- 7 Kittens
- 8 Kittens
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Litter 2 Numbers if applicable
- N/A
- 1 x Adult Female (mother)
- 2 x Adult Females (mothers)
- 3 x Adult Females (mothers)
- 1 Pup
- 2 Pups
- 3 Pups
- 4 Pups
- 5 Pups
- 6 Pups
- 7 Pups
- 8 pups
- 1 Kitten
- 2 Kittens
- 3 Kittens
- 4 Kittens
- 5 Kittens
- 6 Kittens
- 7 Kittens
- 8 Kittens
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Area Collected
- Appin South
- Bael Bael
- Beauchamp
- Benjeroop
- Budgerum East
- Cannie
- Cullen
- Cohuna
- Daltons Bridge
- Dingwall
- Gannawarra
- Gonn Crossing
- Horfield
- Kangaroo Lake
- Kerang
- Kerang Airport
- Kerang East
- Koondrook
- Lalbert
- Lake Charm
- Lake Meran
- Leitchville
- Macorna North
- Mead
- Meatian
- Meering West
- Milnes Bridge
- Mincha West
- McMillans
- Murrabit
- Murrabit west
- Myall
- Mystic Park
- Ninyeunook
- Normanville
- Quambatook
- Sandhill Lake
- Teal Point
- The Bannacher
- Tragowel
- Wandella
- Wee Wee Rup
- Westby
- Other
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Colour
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Sex
- Male -Entire
- Female - Entire
- Male desexed
- Female desexed
- Unknown due to being too young to determine
- Unknown Due to Illness / Injury causing the animal pain
- Unknown Due to Aggression / Risk to Officer
- Mixed due to litter numbers.
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Approx Age
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Rego Tag (if applicable)
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Microchip/s (if applicable)
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Officers Notes
Persons Details
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Name
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Address
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Contact number
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Persons Declaration - By surrendering the animal described herein and checking the acceptance box I acknowledge the animal will be assessed by Gannawarra Shire Council for rehoming. I agree that based on that assessments outcome the animal may be removed to a rehoming facility of a third party, or if deemed unsuitable to re-home it will be processed in accordance with provisions of Council Policy and The Domestic Animals Act 1994.
- I the person named herein being the sole legal owner of the animal/s described have read and accept the Declarations terms regarding my animals surrender to Gannawarra Shire Council.
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Photo of persons ID / Concession card
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Person surrendering to sign
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Time date completed
