Camden Council Animal Seizure/Surrender Forms

Animal Seizure/Surrender Form

• Document No.

• Officer

  Renee Galinaitis

  Michelle Gallo

  Jennifer Rowe

  Nathan Armytage

  Matthew McNaughton

• CRM created

  Yes

  No

  Unknown

• CRM Number

Seizure/Surrender Information

• CRM number

• Officer

  Renee Galinaitis

  Michelle Gallo

  Jennifer Rowe

  Nathan Armytage

  Matthew McNaughton

• Officer Signature

  Sign

• Time and Date of Seizure/Surrender

  Date

• Surrender or Seizure

  Surrender

  Seizure

• Reason

• Customer or Owner

  Customer

  Owner

• Customer/Owner Details

• Location/Address of Seizure/Surrender
  Address

• Location where Animal was Found

• Declaration

  I am NOT the owner of the animal

  I am the Owner of the animal

  I am an Authorised Agent for the owner of the animal

• I surrender all my right title and interest in the animal to camden council and agree that it becomes the sole and absolute property of the council, who is authorised to HOLD, SELL or DESTROY it as the council or any member of the same in it's or their discretion deems fit.<br>I agree to indemnify council and keep the council indemnified against all claims (if any) costs, expenses whatsoever arising out of any action by any person claiming an interest contrary to that expressed in the declaration.

  I agree

  I disagree

• Signature of customer/owner

  Sign

• Photo of signed Seizure/Surrender Form at vets

  Media

Animal Information

• Animal type

  Select Dog Cat Goat Sheep Horse Cow Pig Other

  • Dog
  • Cat
  • Goat
  • Sheep
  • Horse
  • Cow
  • Pig
  • Other

• Breed

• Sex

  Male

  Female

  Unknown

• Age

  Adult

  Juvenile

  Senior

  Baby

  Unknown

• Colour

• Microchipped

  Yes

  No

  Unknown

• Microchip number

• Animal registered

  Yes

  No

  Unknown

• Previous Impound History

  Yes

  No

  Unknown

• Additional comments/Information

• Picture of Animal

  Media

Transportation of Animal

• Destination of animal

  Pound

  Returned to Owner

  Released to Agent

  Vet

  Other

Impound information

• Impound tag number

• Release information

  Select Release to Owner/Agent Reclaim Only Owner to contact Council Contact Council on Release Under Investigation Do Not Release

  • Release to Owner/Agent
  • Reclaim Only
  • Owner to contact Council
  • Contact Council on Release
  • Under Investigation
  • Do Not Release

• Name and signature of Pound officer

  Sign

Microchip Details

• Owner Details

• Address

• Contact number

• Additional information

• Has the owner been contacted

  Yes

  No

  Unknown

Release to Owner/Agent

• Owner or Agent

  Yes

  No

  N/A

• Details match microchip details

  Yes

  No

  Unknown

• New contact details (if they don't match microchip) eg address, contact numbers

• Identification

• Name & Signature of Owner or Agent

  Sign