Tech_Exhibit_0802_Stray_Animal_Intake.docx

Stray Animal Intake Form

Please help us provide great care for this animal by thoroughly completing the following information. Thank you!

Name:

Date:

First Last Address:

Street City State Zip Home

Phone:

Alternate

Phone:

Where did you find this animal (include address if known):

When did you find the animal?

Was the animal wearing a collar or ID? YES NO

If yes, please describe:

To your knowledge, has this animal bitten anyone within the past ten (10) days? YES NO

If yes, please describe the incident:

Please review and sign below acknowledging the following:

· This animal is, to the best of my knowledge, a stray or un-owned animal.

Print Name: _ _ _ Signature: _

Date: _

STRAY,

SEEMS

OWNED

STRAY,

DOESN’T

SEEM

OWNED

S/N

DECLAW

COLLAR

MICROCHIP:

SPECIES:

NAME:

GS-

BREED:

AGE

GROUP:

ID#

COLOR:

INT.

CONDITION:

ROOM:

SEX:

SIZE:

S M L

XL

NAME:

GS-

BREED:

AGE

GROUP:

ID#

COLOR:

INT.

CONDITION:

M L

XL

)Stray Book-In Information

STAFF: DATE:

NAME:

GS-

BREED:

AGE

GROUP:

ID#

COLOR:

INT.

CONDITION:

M L

XL

NAME:

GS-

BREED:

AGE

GROUP:

ID#

COLOR:

INT.

CONDITION:

M L

XL

NAME:

GS-

BREED:

AGE

GROUP:

ID#

COLOR:

INT.

CONDITION:

M L

XL

NOTES: