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_� Z r <br />VICTIM OF BITE: - .. _ Name <br />RDSM=4 ANIMAL <br />QUARANTINE FORM <br />Breed <br />Height <br />City License# <br />Veterinarian's name <br />Weight <br />Sex <br />. _ Ponq Hair _ <br />Yr Is animal a <br />Telephone Nor <br />Vaccination Certificate Neer <br />Age Address <br />Wcatlon of bite <br />And further information <br />OWNM OF ANDIAT. } Nance <br />ANIML IMPOUN= AT: <br />NO W-, <br />t. <br />IN A=RDMCE WITH IA W,, this -animal will be impounded at the location specified above,, at the <br />expense of the owner, for a Tnxi mtum period of ten days from the tine of the bite. If during <br />the initial ten day quarantine period, the animal shows any signs or synptcos of rabies, the <br />quarantine will be indefinitely extended, The animal will not be disposed of during the <br />quarantine. <br />QL?JV24= AGREEMENT <br />I understand the aloe order and I agree to irrpoun1- r, aril, at tense, in h or at <br />a licensed veterinary hospital. If the animal dies or becomes sick during the ten days of con- - <br />finement f I will personally notify the Roseville Police Departrnmt ` ' atel . I will not re- <br />mve the an ml fro n quarantine until it has been inspected by a representative of the City. <br />I will not eve the aninul from the City witrhout - pe =ssion fry the fief of Police, I <br />understand that any violation of these conditions may cause rry animal to be in pounded at a <br />police facility at nTy expense and may subject ne to criminal penalties. <br />Animal Owner <br />I ccnsent to the quarantine as provided herein. <br />Bite Victim <br />Hospital impound verify <br />officer <br />i - <br />