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