The Humane Society of Kent County, Maryland, Inc.

Kent County
Animal Control Section
Report of Complaint or Problem
  
Ways to submit this information:

· FAX this form to 410-778-7371
· MAIL this form to: Kent County Humane Society,.
10720 Augustine Herman Hwy, Chestertown, MD 21620
· PHONE 410-778-3648 or toll free 1-866-661-PETS
to make a report (10:30-5:30 Tues,Thurs, 10:30-3:30 Fri, 9:00-12:00 Sat.)
After hours emergencies involving safety to persons or animals 410-778-1241

Please print or write all information clearly. Attach additional pages if needed.

Your (Reporting Party’s) Name: ___________________________________________________

Address: ______________________________________________________________________

City________________________________ State____________ Zip Code __________________

Phone Number: ( ______ ) ________________ Alternate Phone: ( ______ ) _______________

Animal Owner’s Name: _________________________________________________________

Address: ______________________________________________________________________

City________________________________ State____________ Zip Code __________________

Phone Number: ( ______ ) ________________ Alternate Phone: ( ______ ) _______________

Animal(s) involved and their description: __________________________________________ ______________________________________________________________________________

Please describe the nature of the complaint or problem, with all pertinent information including dates, times of incident(s), location of violation(s) and names and phone numbers of witnesses. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Signature: __________________________________ Date: ___________________________

01-02 For office use: Case #______________________ Date Stamp In: ____________________________ ____________________________