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Siskiyou Humane Society
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Date:_____________________________________
Name of Facility:_________________________________________________________________________________
Address:__________________________________________________________________________________________
Contact Person and Phone #:_______________________________________________________________________
Name of Applicant:________________________________________________________________________________
Address and Phone #:______________________________________________________________________________
Type of Pet:________________________________Name:______________________Age:____
Date Approved:______________________________By:________________________________
Facility Representative Signature______________________________________________
Applicant Signature____________________________________________________________
Deposit must be returned to the Siskiyou Humane Society in the event this animal no longer resides in this facility. Your signatures above assures compliance with this agreement. This form will be on file at the SHS, with copies given to the tenant and the facility.
Date of Cancellation:____________________________________ Amount Repaid_________________________
Back to the archives June, 2006