BLEAKHOLT ANIMAL SANCTUARY

DOG / CAT ADMISSION / RETURN Ref: _________

I am the Owner / Finder* of _________________________________ (Dog / Cat *)
(* Please delete)

I ________________________________________ OF ___________________________________________________

________________________________________________________ TEL ___________________________________

Give authority to Bleakholt Animal Sanctuary to take this animal and re-home it in whatever way they consider best for the animal. I relinquish all claims to the animal and understand that I cannot be told where he/she has been placed.

Signed _______________________________________  Date ______________________________

Witnessed by (staff member) _________________________________   Donation ______________________


NAME _________________________________  COLOUR ___________________________

BREED ________________________________   SEX: M / F   NEUTERED: Y / N    AGE ________

LAST SEASON __________________________   VACCINATED   1   2   BOOSTER DUE ____________

MICROCHIPPED: Y / N    NUMBER _______________________________________

DATE LAST WORMED _______________________________   PRODUCT USED ___________________________

DATE LAST FLEA TREATMENT ______________________________   PRODUCT USED ______________________

FOOD TYPE ___________________________   FREQUENCY _______________________________