Borzoi Rescue – Northern California
Surrender Agreement, Page 4
Borzoi Rescue – Northern California
SURRENDER AGREEMENT
Occasionally, a Borzoi cannot remain in its current situation and a new, permanent home is needed.Borzoi Rescue – Northern California, Inc. (BR-NC) agrees to take such dogs into its Rescue Program and provide adequate daily care and any needed veterinary care until the dog is placed through adoption.
The undersigned legal owner/s agree to transfer ownership of the Borzoi listed below and to relinquish all rights to and responsibility for the dog(s) from this date forward. The owner/s also agree to supply any registration certificates and veterinary health records available.
BR-NC respectfully requests a donation of $100 to help cover our costs – however, no dog will be refused. As an all-volunteer nonprofit organization, BR-NC depends on the generosity of concerned animal lovers. All donations are greatly appreciated and go toward animal care. Donations are tax-deductible as allowable by law.
Dog's Name ______
Sex ______Age ______Date of Birth ______/______/______
Microchip and/or tattoo # ______AKC or other Registration # ______
Breeder's Name &/or Kennel Name ______
Breeder’s City/State ______
Phone ______Email ______
Please check ONE of the following boxes:
I am the breeder of this dog and relinquishing all current and future rights to it.
I know the breeder of my Borzoi and/or have a registration number for my Borzoi, and I consent to having the dog returned to its breeder.
I do not know the breeder of my Borzoi and/or do not know if the dog was registered, but I consent to having the dog returned to its breeder if located.
Under no circumstances is my Borzoi to be returned to its breeder. I stipulate that this requirement be honored by BR-NC throughout the lifetime of this dog.
Where and when did you obtain the Borzoi? ______
______
Veterinary health records available? Yes No
Veterinarian's Name ______
City/State ______Phone ______Email ______
Is the dog spayed or neutered? Yes No
If the dog is female and not spayed is there any chance she may be pregnant? Yes No
Is the dog currently on any medication or have any health problems? Yes No
If YES, please list any health problems, as well as the name of medications, reason for medication, and instructions. ______
MEDICATION REASON DOSAGE TIME GIVEN
______
______
______
What brand and type of food has the dog been eating? Please be specific!
______
When is the dog fed? ______How much food? ______
Where is the dog typically fed? ______
Any other food-related information? ______
______
Where is the dog kept? Indoors Outdoors Where does the dog sleep? ______
______
______
Describe the dog's temperament and adaptability. ______
______
______
______
Obedience trained? Yes No Explain: ______
______
Leash trained? Yes No Explain: ______
Crate trained? Yes No Explain: ______
______
Housebroken? Yes No Explain: ______
______
Good in cars? Yes No Explain: ______
______
Children? Yes No Explain: ______
______
Men? Yes No Explain: ______
______
Women? Yes No Explain: ______
______
Male/Female dogs? Yes No Explain: ______
______
Cats? Yes No Explain: ______
______
Other Animals? Yes No Explain: ______
______
Frightened by thunder or loud noises? Yes No Explain: ______
______
Jumps or digs under fences? Yes No Explain: ______
______
Destructive to yard or other property? Yes No Explain: ______
______
Has the dog bitten or have a history of aggression? Yes No If YES, explain in detail:
______
______
______
______
______
Please list any special commands, games, tricks. etc.
______
______
______
Anything else? ______
______
______
Please check one:
I am enclosing a donation of $______to help defray the costs of placing my dog(s).
I am not making a donation.
My/Our signature/s means that all information listed above is true, as I/we know it, and that I am/we
are the sole owner/s of the above-mentioned Borzoi being surrendered to Borzoi Rescue – Northern
California, Inc.
SURRENDERING OWNER ______DATE ____/____/____
Printed Name
______
Signature
Street Address ______
City/State/Zip ______
Phone (home) ______(work) ______(cell) ______
E-mail ______
Please initial one: ____ I wish my personal information to remain private.
____ My personal information can be disclosed if needed.
SURRENDERING OWNER ______DATE ____/____/______
Printed Name
______
Signature
Street Address ______
City/State/Zip ______
Phone (home) ______(work) ______(cell) ______
E-mail ______
Please initial one: ____ I wish my personal information to remain private.
____ My personal information can be disclosed if needed.
BORZOI RESCUE — NORTHERN CALIFORNIA, INC. REPRESENTATIVE
______DATE ____/____/_____
Printed Name
______
Signature
Please return to:
Nancy Joeckel, Treasurer
Borzoi Rescue – Northern California, Inc.
PO Box 1850, Rogue River OR 97537
Phone & Fax: (541) 582-8220
Email:
Revised 7/2017