DOG SURRENDER AGREEMENT

It is preferable that this form is completed digitally, with the exception of page five, which should be handwritten and signed. This is to aid data entry for SA Dog Rescue record keeping. Please inset text in the box below each heading. Please provide as much detail as possible. The boxes marked with an asterisk * must be filled in.

Dog(s) name
* / Breed / Gender
M/F / Birth date*
(estimate if not known)
dd/mm/yy / Colour / Distinguishing features
Surrendered from *
(surname and given name) / Council Reg No. / Microchip Number / Is the dog de-sexed?* Y/N / Tattoo(details)
Reason for Surrender / Did you contact the breeder? (y/N) / Where was the dog obtained?

INSERT PICTURE OF SURRENDERED DOG HERE

HEALTHand immunisation

Date immunisation due* (dd/mm/yy)
Vet record available Y/N / C3 / C5 / Kennel cough / Flea treatment / Heartworm / Intestinal worms
What food is fed regularly to the dog
Other comments

BEHAVIOUR

Housetrained Y/N
Crate trained Y/N
Obedience training None/basic/intermediate/advanced
Biting Y/N
Destructive behaviour (type, eg chewing, scratching, digging, etc)
Escapes Y/N
Is the dog used to other dogs, cats, other animals children (All that apply)
Behaviour issues i.e. fear, anxiety, separation anxiety food protection
Any other information that may help us place the dog in a new home

OFFICE USE ONLY

SA DR Shelter number
Date dog received
SADR Representative
Dog placed shelter
Dog placed Foster carer

RELEASE /SURRENDER

I/We state that I/We are the sole owners of the above described dog and that no other party have a legal or financial interest in this dog

I/we state that all the information given in this document is true to the best of my/our knowledge. In the event that misleading information is provided on this form, SA Dog Rescue is entitled to recover costs from the signatory that relate to loss arising from any false declaration or deliberate omission.

I/We relinquish all rights, interest and ownership of the above dog to SA Dog Rescue and hereby relinquish all claims to said dog.

I/We understand that this surrender is irrevocable and ownership of said dog is relinquished to SA Dog Rescue

I/We further understand and agree that I/We will receive no money or any other compensation as a result of this surrender

Any donation made to SA Dog Rescue does not constitute a sale and this donation will be used to benefit future SA Dog Rescue activities relating to dog rescue

This surrender is made on this day______of______year ______

Surrendering owners name (print)______sign______

Address______

Phone numbers______

Witnessed by ______

SADR Surrender Agreement July 2010