Leichhardt Rangers IMPOUND FORM

• Audit Title

• Conducted on

  Date
• Location
  Address

• Conducted by

  Select Ronnie Busuttil David Chariton Bang Le Peter Lee Peter Parker Preet Singh

  • Ronnie Busuttil
  • David Chariton
  • Bang Le
  • Peter Lee
  • Peter Parker
  • Preet Singh

• DWS #

IMPOUND INFORMATION

• Animal impounded

  Date

• Impound reason

  Wandering at large

  Relinquished

  Dog attack

  Hold

  Abandoned

ANIMAL INFORMATION

• Animal

  Dog

  Cat

  Other

• Breed

• Colour

• Age

• Gender

  Male

  Female

  Unsure

• Desexed

  YES

  NO

  UNSURE

• Registration tag

• Microchip No

• Collar / Distinguishing Marks

• Animal Photo

  Media

• Any obvious injuries or suspected medical issues with the animal at time of collection

• Photo of injuries

  Media

Animal impounded at

Companion Animal Register OWNER INFORMATION

• Owner Details

• Address

• Phone Number

• Date Contacted

  Date

RELEASE INFORMATION

• Release Reason

  Select Owner Welfare Group Euthanised

  • Owner
  • Welfare Group
  • Euthanised

• Name of Welfare Group

• Officer

• Add signature

  Sign

• Date

  Date

• Copy of forms

  Media

Leichhardt Council, and its consultants, partners, agents and employees shall not be held liable for any and all claims, losses, expenses, injuries or damages arising by reason of any act or omission, including negligence not amounting to a wilful or intentional wrong during the period of time within which the above described animal was not in your custody or under effective control.

• Infringement Number

RELEASED/REHOMED/EUTHANISED