OWNER’S SURRENDER AGREEMENT
The undersigned, being the owner or the fully appointed agent of the dog described below and in the accompanying Owner Surrender Form, does hereby affirm, acknowledge and warrant and represent that all information contained in this profile is true and correct to the best of their knowledge and belief, should any information set forth be discovered to be false, untrue or misleading in any respect at any time, then Northwest Hills K-9 Rescue, Inc.(NHKR) shall have the right to (1) rescind this agreement and require the owner to take the dog immediately into his/her possession and/or (2) require owner to pay all costs incurred in the care, placement or disposition of the dog, further, should any of the information set forth in this document be discovered to be false, untrue or misleading in any respect at any time, then owner agrees to indemnify and hold NHKR harmless by, from and against any and all claims, suits, damages, liabilities and costs (including reasonable attorney fees) related to or in any manner connected with this dog.
I understand that NHKR will utilize the information contained in this form to assist in selecting an appropriate Foster Home and Adoptive Home. I understand that I will be held liable for any and all claims, suits, damages, liabilities and costs (including reasonable attorney fees) related to or in any manner connected with this dog that is a result of any false, untrue or misleading information provided in this form that therefore results in the dog being placed in an inappropriate home, situation or environment.
I understand that NHKR will make every effort to find a loving home for my dog and grant my permission to contact all of the medical service providers named in the Owner Surrender Form and hereby grant permission for the release of all records and information in their possession.
I understand that NHKR will have full ownership of the dog effective immediately upon surrender and that I will not be permitted to see or visit it at any future date. I understand that I may contact NHKR periodically to inquire as to the dog’s wellbeing, but that I will not be informed of the dog’s whereabouts or provided with any identifying details regarding the dog’s foster or adoptive home.
THIS IS INTENDED TO BE A LEGALLY BINDING AGREEMENT. IF NOT FULLY UNDERSTOOD SEEK THE ADVICE OF AN ATTORNEY PRIOR TO SIGNING.
I HEREBY RELINQUISH OWNERSHIP OF THE ABOVE-MENTIONED DOG TONORTHWEST HILLS K-9 RESCUE, INC. SIMULATENOUSLY WITH THE EXECUTION OF THIS AGREEMENT. FURTHER, I ALSO TURN OVER PHYSICAL POSSESSION OF THE DOG TONORTHWEST HILLS K-9 RESCUE, INC. SHOULD PHYSICAL POSSSESSION OF THE DOG NOT BE RELINQUISHED SIMULTANEOUSLY THIS AGREEMENT SHALL BE NULL AND VOID.
Dog Name: ______Microchip Number (if implanted): ______
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Print Surrendering Owner Name
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Signature Date
WITNESS:
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NHKR Representative
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Signature Date