Title Page

  • Time Date

  • Officer/s Receiving

  • CS Number

Animal Details

  • Surrender Reason / Behavior concerns

  • Animals Name

  • Species

  • Breed Type

  • Photographs

  • Litter 1 numbers.

  • Litter 2 Numbers if applicable

  • Area Collected

  • Colour

  • Sex

  • Approx Age

  • Rego Tag (if applicable)

  • Microchip/s (if applicable)

  • Officers Notes

Persons Details

  • Name

  • Address

  • Contact number

  • 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.

  • Photo of persons ID / Concession card

  • Person surrendering to sign

  • Time date completed

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