Release of Ownership Agreement/Dog Personality Profile

Maltese Rescue California (MRC)

Release of Ownership Agreement/Dog Personality Profile

www.malteserescuecalifornia.org

Name

Dog's Name

Phone

Address

City, State Zip

E-mail

Click to edit

MonthDayYear

I certify that I am the owner of this dog, free and clear of all other interests, until this surrender is signed.

I certify that this dog is not possessed of any dangerous or vicious propensities and has never bitten or attempted to bite any person or animal, and that the dog is not ill. I further certify that I have not willfully concealed information about the dog that might indicate any vicious propensities or illnesses.

I hereby forever release, discharge and agree to hold harmless and indemnify Maltese Rescue, its Board of Directors, its officers, members, agents and volunteers from all claims, demands, actions, causes of action, and liability of any kind whatsoever arising as a result of or in connection with the surrender and subsequent adoption or other disposition of this surrendered dog. I understand that I give up all rights and ownership to the dog and this is a legally binding contract and cannot be rescinded.

I hereby give permission for my veterinarian to release all vet records of this dog to the Maltese Rescue California.

Veterinarian/Clinic

Vet/Clinic's Phone

Vet/Clinic's Address

I have read the above and understand that by executing this document, I hereby surrender all rights and claims to the animal aforementioned..

Statement of Understanding

Under the E-Sign Act of 2000, Maltese Rescue California requires that you certify your application by submitting an electronic signature. To certify your application, (type your name) and click the Confirm Signature radio button.

Owners Signature / E-Signature

Print your name in space below if signing as E-signature

Type your Name here

Click to edit

MonthDayYear

Witness Signature

Witness Full Name

First NameLast Name

I certify that this is my signature and that all information is accurate and true.

MY DONATION TO HELP DEFRAY THE COST OF THIS RESCUE EFFORT IS:

donation amount

Dog Personality Profile:

Dog's Name, Age, Sex, and Weight:

Dog is

choose one

If not spayed: date of last heat cycle:

MonthDayYear

How long has the dog lived with you?

Where did you get the dog?

Why are you giving up the dog?

Does the dog have a microchip?

If Yes, Microchip Manufacture and microchip number?

This dog is current on vaccinations?

Date of last Rabies?

Date

Date of last DHPP?

Date

Date of last Bordetella?

Date

Date of last Heartworm test?

Date

Does your dog have any special problems/medical conditions or is on any medications?

If Yes: Explain:

May we (MRC) contact his/her vet?

Veterinarian/Clinic

Vet/Clinic's Phone

Will your vet/clinic provide shot records?

Dog's Lifestyle:

Is this dog completely housetrained?

Where is this dog kept during the day?

How many hours is this dog typically left alone per day?

Does this dog have a history of destructive habits?

Explain if Yes, and how often?

Does this dog have a history of escaping?

Explain if Yes?

How much exercise is this dog accustom to?

Is this dog accustomed to car rides?

Is this dog accustomed to being kenneled?

Has this dog ever attended obedience classes?

How would you describe this dog most of the time?

What are some things you truly love about this dog/greatest traits?

What toys or activities does this dog enjoy?

Is this dog used to living with other animals?

Does this does have any fears or phobias?

Explain if Yes:

Has this dog been around children?

How does this dog act with children?

Has this dog ever done the following to an adult?

If Yes, what were the circumstances?

Signature

I certify that this is my signature and that all information is accurate and true.