Surrender & Re-Homing Request Form
Because of the volume of surrender requests we receive, no phone calls please.
Our Surrender Committee meets once every 2 weeks - it may take up to 15 days before you receive a response from us.
There is no fee for applying, however donations are always appreciated to help support surrendered and re-homed animals.
Date *
Name (First, Last) *
Email: *
Street Address: *
City / State / Zip *
Contact Phone number: *
How did you obtain the animal? *
How long have you owned the animal? *
Name of Animal: *
Breed: *
Color: *
Weight: *
Male or Female: *
Age: (Please give Date of Birth if known) *
Is the animal "House Trained"? *
Registration No: *
Reason for Surrender: *
Does the animals have any health problems? *
If "Yes" please explain. / If "No" please type, "No known health problems or issues." *
Is the animal up to date on vaccinations?
Clear selection
Do you have vet records: *
What is the name and telephone number of the vet that has given the animal its most recent care? *
Please include any additional information regarding the animal here: *
Please list the items that you will be donating to us with the animal so we can properly prepare for animals arrival to us. *
By checking the below box, I understand that if I surrender an animal to Darby Acres Farm, I give up all rights to that animal. I understand that I am giving up forever all rights, title and interest to the surrendered animal and further understand that my surrendered animal may be re-homed and/or adopted /sold to another home and I will not be given written or verbal updates on any surrendered animals and that all future decisions regarding this animal will be made solely by Darby Acres Farm. *
By checking the below box, I declare that I am the person named above as the owner of the animal described above. I further declare that the information above is true and correct in every detail. I hereby certify that I am the owner of the animal described above. I also certify that I have unrestricted and complete authority to convey, surrender and relinquish the animal to Darby Acres Farm, and I hereby further certify that the animal has not bitten anyone in the last 15 days. *
Signature: *
NC License Plate No. (REQUIRED) *
Any additional Comments, Questions, and/or Concerns:
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