Date

City Tag Number

Owner

Address

Phone Number

Dog's Name

Breed

Color

Male or Female Male or Female Female Male

Any Other Noticable Characteristics

Rabies Vaccination Tag Number

Date of Vaccination

Name of Veterinarian Who Gave Shot

Veterinarian Address

Vaccination Serial Number

Adoption Adoption

Adopter's Name

Adoption Date

Adoption Fees

On this date the animal control officer for the City of Columbus, KS does hereby release the above mentioned dog to above mentioned name for adoption, K.S.A. 47-1701 states all dogs we be sterilized when released for adoption. By signing this form, he or she is agreeging to sterilize their new pet at their own expense.

Adoptor Signature