Owner Relinquishment

Name of Releaser*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail:*

Phone Number:*

Area CodePhone Number

Dog's Name:*

Age:*

Color*

Gender:*

Releaser releases the above described animal to the Rescue Service and warrants that he has clear title, free of any other claim. As long as the animal remains in the possession of Releaser, Releaser remains responsible for its actions and agrees to hold Rescue Service harmless from any claims arising there from. If the animal remains in the possession of Releaser until the Rescue Service is able to place it in a suitable home, it is understood and agreed that the dog isthe property of Rescue Service, and that neither Releaser nor anyone on his behalf shall take any action on behalf of the animal inconsistent with the Rescue Service's ownership. Releaser warrants that he has fully and completely disclosed to the Rescue Service all information known to Releaser concerning the temperament and behavior characteristics of the animal being released. Releaser warrants that to the best of his knowledge, this animal has never bitten any person, nor shown aggressive behavior toward any person, nor had any serious medical problems, except as follows:

Neutered/Spayed:*

YesNo

Name of Veterinarian:*

Heartworm test date and results:*

Heatworm preventative used:*

Innoculations/dates

DHLPP*

Rabies*

Rabies tag #:*

Medications:*

Preferences:*

(men, women, children, small children)

Bad habits:*

(barking, chewing, cats, other dogs)

Date of relinquishment:*

MonthDayYear

Signature(s) of Releaser(s):*

Your printed name constitutes agreement with the relinquishment.

Enter the message as it's shown*

OWNER RELINQUISHMENT FORM