Corgi Rescue of Eastern New York
31 Sage Road, Waterford, NY 12188
Kathy Moore, Director
Owner Surrender Agreement
Name of Owner (s)
City: State: Zip:
Home Phone: Cell Phone:
Name of Dog: Male or Female
Date of Birth/Age: Weight:
What dog food is he/she on? Amount per feeding?
Registered with AKC or other organization?
Proof of ownership (sales receipt or contract)
If purchased from directly from a breeder, is there a contract? Yes No
If yes, does the contract require you to return the corgi to the breeder if you are not able to keep it? Yes No
Veterinarian: Address: Phone:
Date of last vaccinations: Last Heartworm blood test: Results:
Heart worm medication:
Medications currently taking:
Circle, Highlight or Bold All that Apply:
Does the dog like? other dogs cats children strangers
Does the NOT dog like? other dogs cats children strangers
Where does the dog stay? loose in the house crated tied chained doghouse loose in yard
yard at all times other:
Habits: housebroken crate trained leash broken obedience training marks territory howls/barks runs away
Temperament: Friendly enthusiastic anxious to please outgoing reserved protective cautious
shy timid stubborn calm lethargic aggressive dominant submissive other:
Owner Surrender Agreement-Corgi Rescue of Eastern NY
Other comments regarding behavior:
Reason for relinquishing:
I certify that this dog has not bitten a human and is not under any quarantine restrictions _____ initials.
I do hereby release full ownership of my dog to Corgi Rescue of Eastern New York (known as CRENY in this
document). I understand that with this instrument the dog becomes the property of CRENY.
I also agree that no legal liability will befall the CRENY, either by this owner or any previously unknown owners.
I will make no attempt to reclaim my dog, although I am welcome to contact CRENY to see how my dog is doing.
I fully grant CRENY the right to give my dog any medical treatment deemed necessary and to place the dog in an
approved adoptive home. Should a vet determine my dog is too ill to be treated, I give CRENY the right to put said
dog humanely to sleep.
I release CRENY, from all liability, legal or otherwise concerning said animal. CRENY will make every attempt to
provide adequate foster care, but is not liable for any action of said animal or accident sustained.
I give permission to CRENY and its volunteers to contact my veterinarian regarding my corgi. I give my
veterinarian permission to provide copies of my corgis health records for use by CRENY and the new owner,
and their veterinarian.
I hereby state that I am giving up my dog of my own free will. It is also noted that Corgi Rescue of Eastern New
York will not be accused of stealing or forcing the giving up of any animal turned over, by myself, to CRENY
By signing this agreement, I fully understand and accept the terms of this Owners Surrender
If completing online, please type name above, your email will act as your electronic signature until the original is
presented at the time of the surrender.
Please have all registrations & microchip transfer forms signed, original vet records, etc. available at the time of the
Any items such as a crate, toys, medicine, etc that comes with the dog will go with the corgi to their new home.