Government of Rajasthan Animal Husbandy Department CONSENT FORM FOR EUTHANASIA Species--------------------------------Sex ----------------- Age---------------------- Breed -----------------------------Colour---------------------------------------------- Identificaton marks-------------------------------------------------------------------- I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the above mentioned animal, that I do hereby give the veterinarian/his representative --------------------------------------------------full and complete authority to destroy the said animal in whatever manner the said veterinarian/his representative shall deem fit, and I do hereby forever release the said veterinarian/his representative from any and all liability for so destroying the animal. I do also certify that to the best of my knowledge the said animal has not bitten any person or animal during the last fifteen (15) days, and has not been exposed to rabies. Place---------------- Date ----------------- (Signature of the owner/Authorised Agent) Name------------------------------------------- Address---------
