"Animal Intake Form" - Alabama

Animal Intake Form is a legal document that was released by the Alabama Department of Agriculture and Industries - a government authority operating within Alabama.

Form Details:

  • Released on November 1, 2006;
  • The latest edition currently provided by the Alabama Department of Agriculture and Industries;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Alabama Department of Agriculture and Industries.

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Download "Animal Intake Form" - Alabama

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Animal Intake Form
TODAY’S DATE:
RECEIVED BY: (PLEASE PRINT)
OFFSITE STATUS (If Applicable)
OUT DATE
LOCATION
RETURN DATE
ARRIVING STATUS OF ANIMAL
REQUESTED RESCUE?
YES
NO
RESCUED
IF YES, WHO REQUESTED IT?
DROPPED OFF
OWNER
OTHER ____________________
DEAD ON ARRIVAL
ARE YOU THE OWNER?
YES
NO
If not, what is your relationship to the animal? _________________________________________________________________________
CONTACT INFORMATION
NAME:
ADDRESS:
CITY/STATE/ZIP:
HOME PHONE:
WORK PHONE:
CELL PHONE:
(
)
(
)
(
)
ALT. PHONE:
E-MAIL ADDRESS:
(
)
DRIVERS LICENSE NO.:
STATE:
PERMISSION TO FOSTER?
SURRENDERED?
YES
NO
YES
NO
LOCATION OF ANIMAL PICKUP (Give address if known and landmarks)
ANIMAL INFORMATION
DOG
CAT
HORSE
REPTILE
OTHER: ___________________________________________
LITTER (Under 8 weeks old) NUMBER IN LITTER: ______________
MALE
FEMALE
NEUTERED
SPAYED
UNKNOWN
BREED: ___________________________________________
SMALL
MEDIUM
LARGE
TAIL:
LONG
SHORT
CURLY
EARS:
ERECT
FLOP
AGE:
BUSHY
DOCKED
CROPPED
YOUTH
ADULT
SENIOR
IF CAT, IS IT DECLAWED?
FUR LENGTH:
COLOR(S):
YES
NO
DISTINGUISHING MARKS?
ANIMAL’S NAME (If known):
MICROCHIP
TATTOO
NUMBER: _______________________________________________________________________________
COLLAR?
YES
NO
ID TAG?
YES
NO
NAME/PHONE NUMBER: ___________________________________________________________________
TYPE/COLOR: _______________________________________________________
COUNTY RABIES LICENSE NO./YEAR:
ISSUING COUNTY:
ATTEMPT TO CONTACT COUNTY (Date & Result):
IS ANIMAL AGGRESSIVE?
IF YES, WHAT IS THE ANIMAL AGGRESSIVE TOWARD?
HAS ANIMAL BITTEN ANYONE?
YES
NO (If YES, Mark Cage)
PEOPLE
DOGS
OTHER ANIMALS
YES
NO
ATTEMPTS TO CONTACT OWNER
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
MEDICAL INFORMATION
KNOWN DISEASE STATUS:
TYPE: ______________________________________
POS
NEG
TYPE: __________________________________________
POS
NEG
_____________________
KNOWN VACCINATION STATUS:
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
_____________________
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
_____________________
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
KNOWN INJURIES/MEDICAL HISTORY: ______________________________________________________________________________________________________________________________
MEDICATIONS NEEDED: __________________________________________________________________________________________________________________________________________
DEPARTING STATUS OF ANIMAL
DATE RECLAIMED: _________________ OWNER’S SIGNATURE: ___________________________________________ DRIVER’S LICENSE NO.: ______________________ STATE: _____
PRINT NAME: ___________________________________________________ PHONE NO.: _______________________________________________
DATE FOSTERED/ADOPTED: ________ (Attach completed foster/adoption agreement to intake form)
PHONE NO.: _______________________________________________
SIGNATURE: ____________________________________________________ PRINT NAME.: _____________________________________________
DATE EUTHANIZED: ________________ REASON: __________________________________________________________________________________________________________________
VETERINARIAN (signature) ________________________________________ PRINT NAME: ______________________________________________
WHITE COPY – RESPONDING AGENCY
YELLOW COPY – OTHER AGENCY
PINK COPY – OWNER (IF KNOWN)
Animal Intake Form
TODAY’S DATE:
RECEIVED BY: (PLEASE PRINT)
OFFSITE STATUS (If Applicable)
OUT DATE
LOCATION
RETURN DATE
ARRIVING STATUS OF ANIMAL
REQUESTED RESCUE?
YES
NO
RESCUED
IF YES, WHO REQUESTED IT?
DROPPED OFF
OWNER
OTHER ____________________
DEAD ON ARRIVAL
ARE YOU THE OWNER?
YES
NO
If not, what is your relationship to the animal? _________________________________________________________________________
CONTACT INFORMATION
NAME:
ADDRESS:
CITY/STATE/ZIP:
HOME PHONE:
WORK PHONE:
CELL PHONE:
(
)
(
)
(
)
ALT. PHONE:
E-MAIL ADDRESS:
(
)
DRIVERS LICENSE NO.:
STATE:
PERMISSION TO FOSTER?
SURRENDERED?
YES
NO
YES
NO
LOCATION OF ANIMAL PICKUP (Give address if known and landmarks)
ANIMAL INFORMATION
DOG
CAT
HORSE
REPTILE
OTHER: ___________________________________________
LITTER (Under 8 weeks old) NUMBER IN LITTER: ______________
MALE
FEMALE
NEUTERED
SPAYED
UNKNOWN
BREED: ___________________________________________
SMALL
MEDIUM
LARGE
TAIL:
LONG
SHORT
CURLY
EARS:
ERECT
FLOP
AGE:
BUSHY
DOCKED
CROPPED
YOUTH
ADULT
SENIOR
IF CAT, IS IT DECLAWED?
FUR LENGTH:
COLOR(S):
YES
NO
DISTINGUISHING MARKS?
ANIMAL’S NAME (If known):
MICROCHIP
TATTOO
NUMBER: _______________________________________________________________________________
COLLAR?
YES
NO
ID TAG?
YES
NO
NAME/PHONE NUMBER: ___________________________________________________________________
TYPE/COLOR: _______________________________________________________
COUNTY RABIES LICENSE NO./YEAR:
ISSUING COUNTY:
ATTEMPT TO CONTACT COUNTY (Date & Result):
IS ANIMAL AGGRESSIVE?
IF YES, WHAT IS THE ANIMAL AGGRESSIVE TOWARD?
HAS ANIMAL BITTEN ANYONE?
YES
NO (If YES, Mark Cage)
PEOPLE
DOGS
OTHER ANIMALS
YES
NO
ATTEMPTS TO CONTACT OWNER
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
DATE: ___________________________ RESULT: _____________________________________________________________________________ BY: _____________________________________
MEDICAL INFORMATION
KNOWN DISEASE STATUS:
TYPE: ______________________________________
POS
NEG
TYPE: __________________________________________
POS
NEG
_____________________
KNOWN VACCINATION STATUS:
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
_____________________
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
_____________________
TYPE:
1 YR
3 YR
LOT #: __________________________________________________________
KNOWN INJURIES/MEDICAL HISTORY: ______________________________________________________________________________________________________________________________
MEDICATIONS NEEDED: __________________________________________________________________________________________________________________________________________
DEPARTING STATUS OF ANIMAL
DATE RECLAIMED: _________________ OWNER’S SIGNATURE: ___________________________________________ DRIVER’S LICENSE NO.: ______________________ STATE: _____
PRINT NAME: ___________________________________________________ PHONE NO.: _______________________________________________
DATE FOSTERED/ADOPTED: ________ (Attach completed foster/adoption agreement to intake form)
PHONE NO.: _______________________________________________
SIGNATURE: ____________________________________________________ PRINT NAME.: _____________________________________________
DATE EUTHANIZED: ________________ REASON: __________________________________________________________________________________________________________________
VETERINARIAN (signature) ________________________________________ PRINT NAME: ______________________________________________
WHITE COPY – RESPONDING AGENCY
YELLOW COPY – OTHER AGENCY
PINK COPY – OWNER (IF KNOWN)